Music & Traumatic Stress: Music Therapy Research and Treatment with Military Populations
By Julie Garrison, MA, MT-BC, Neurologic Music Therapy-Fellow
*This is an article from the Winter 2021-2022 issue of Combat Stress
Since antiquity, music has been synonymous with healing. However, it was not until World War II that the efficacy of music used in clinical settings with United States (U.S.) Veterans showed promise. The U.S. Military Healthcare System acknowledged the value of music interventions with military populations rehabilitating from prolonged stress and trauma. The 1945 U.S. War Technical Bulletin, “Music in Reconditioning in Army Service Forces Convalescent and General Hospitals”1 recognized that medical treatment alone was not enough to assist injured troops,2 as music intervention caused “group cohesion, release of emotions, and esprit de corps.”1 Successful outcomes of music interventions with injured service members led to the development of the music therapy profession. Music therapy is the evidence-based use of music within a therapeutic relationship to help a client improve quality of life.3
Music therapists facilitate music interventions including improvising, recreating, composing, and active and receptive listening to music, within the therapeutic process. This can occur with or without verbal processing4 and addresses the needs of individuals across the lifespan. Music therapists’ practice with at least a bachelor’s in music therapy5 and accomplishment of the credential Music-Therapist, Board-Certified (MT-BC) through completion of an accredited internship and passing the National Certification Board exam.6
Prolonged stress can cause anger, anxiety, depression, withdrawal, avoidance, hypervigilance, negative thoughts about self and/or others, isolation, and grief among other symptoms interfering in daily functioning. Music therapists work towards non-musical treatment goals and outcomes of improving attention to the present, self, and sensations; building resilience, strengthening relationships, supporting community re-integration, nurturing self-expression, improving emotional regulation, fostering identity, and promoting personal growth.34
Neurologic Based Music Therapy Models
Music therapists use a neurologic based approach that integrates trauma-informed music therapy within a neurologic music therapy (NMT) model with clients experiencing traumatic stress, including Veterans, Active-Duty Service Members (SMs), and First Responders.
The Trauma-Informed Music Therapy Model uses a body-centered “bottom-up” approach to address the trauma-recovery model in six stages.17 Bottom-up approaches first focus on sensations, reflexes, and autonomic responses at the brainstem, then move upwards to access and modulate emotional expression within the limbic system, finally accessing cognitive processing tasks of speaking, thinking, and emotional and self-awareness in areas located in the prefrontal cortex.
“Top-down” approaches begin with cognitive processing then move towards autonomic responses. The NMT model of MT uses standardized, research-based clinical interventions grounded in brain-based rationale for how music elements drive changes in the brain and brain connections. These interventions address specific sensorimotor, cognitive, and speech, and language presentations of neurological disease and impairment, including neurologic changes caused by prolonged stress.10
Neurologic Implications of Posttraumatic Stress Disorder (PTSD) and Music Therapy Research
So how does music “heal”? Music characteristics can affect breath, arousal, and movement in the autonomic nervous system (ANS); modulate emotions, access memories in the limbic system; and influence cognitive functioning in the prefrontal cortex (PFC) by activating and deactivating regions of the brain.7,8,9,10 These regions are those that are implicated in the trauma & stress response.11 The brain stem mediates physiologic responses, which, during a trauma response, affect the ANS12 through changes in heart-rate variability and hyper- and hypo-arousal and the startle reflex.
Element of music such as dynamics (e.g., volume, tempo) and timbre (e.g., tone) affect startle reflexes, which can alert impending danger. These responses are enhanced in clients diagnosed with PTSD and linked to trauma exposure due to connection with the amygdala.13 Researchers found that group music therapy assists in auditory arousal reduction through building tolerance of musical instruments’ sound qualities, and learning how to tolerate, communicate, and acknowledge the impact of their instruments on others, leading to a reduction of PTSD symptoms.14 Music elements such as rhythm and tempo can regulate a dysregulated ANS caused by prolonged stress.15 Rhythm can bypass higher cognitive functions such as cognitive processing or emotional regulation, which may be unavailable to those who have experienced complex trauma.16
Music therapists modulate dynamics, rhythm, and tempo, and choose instruments of specific timbres to create safety and stability, promote self-regulation and grounding17 to regulate arousal, and increase parasympathetic and decrease sympathetic tone in the ANS.
Researchers found sympathetic ANS deactivated within a single session of music improvisation18 and music listening, noting improvements in symptoms of fatigue-sleep, anxiety & depression.19 A critical interpretive synthesis of research by McFerran, et al.16 found regular, repetitive rhythms positively influence ANS and have been found to reduce negative PTSD symptoms. Research by Hakvoort20 found that rhythm-based intervention, singing, and psychoeducation helped regulate arousal by decreasing PTSD symptoms of re-experiencing, activation, and avoidance within a group NMT music therapy protocol. Music therapists incorporate rhythm-based interventions and singing, as part of a bottom-up approach and NMT approach to create safety and stabilization by fostering predictability, calm, and pleasure within the music, and self-regulation to improve symptom management.17
The limbic system, which is responsible for emotional regulation, undergoes dysregulation when exposed to prolonged stress. However, music-based experiences can activate and deactivate limbic structures, influencing and changing activity in nearly all brain structures implicated in emotional control.7,9, 21 A systematic review on the neurologic effects of music found that the amygdala activates in response to threat, including music that is unexpected or complex, yet deactivates when music is perceived to be pleasurable,7 and during music improvisation.12, 22 Emotions evoked by music can be exceedingly intense.9 Carr et al.14 found that music improvisation, within group music therapy, significantly reduced PTSD symptoms of avoidance, hyperarousal, and re-experiencing. To access emotions and memories that are difficult to articulate, music therapists incorporate improvisation and songwriting, with or without reference to specific events. This promotes the integration of emotional expression, identity, reconnection, restoration as part of a trauma-informed model in music therapy.17 Additionally, music therapists structure music interventions to promote reconnection, restoration, self-care & maintenance of learned coping skills, reconnection with others, and positive personal resources in music therapy through cognitive means.17
The prefrontal cortex (PFC) region manages high cognitive functioning, including inhibitory control, attention, goal-directed behaviors, planning, and executive functioning, yet are compromised in PTSD.23 Music improvisation deactivates the dorsolateral PFC (dlPFC), a region responsible for cognitive functions such as attention, working memory, maintaining abstract rules, and self-control,24 problem solving, and goal-directed behavior. Yet, during music improvisation, the frontal polar portion of the medial prefrontal cortex (mPFC), the region responsible for internally motivated behavior, self-expression,12, 22, 25 and retrieval of long-term memories25 is activated.22 By engaging in the creative process of music improvisation and composition/songwriting, focused attention and self-monitoring are deactivated (dlPFC) and pathways to access autobiographical memories and associated emotional content are activated (mPFC).22
Hakvoort et al.20 found improvements in sustained attention in adults diagnosed with PTSD using an NMT intervention, Music Attention Control Training, to regulate arousal by changing the tempo activates or deactivates the stress response, which addressed self-regulation skills. The growing body of neurologic-informed music therapy research with traumatized adults supports the U.S. Army’s recognition in 1945, even without the brain-based measures that are now available, that music therapy could help Veterans heal from war trauma.
Therapy in Music Therapy
How does music cause change? Music can be traumatizing if offered without intention, purpose, and understanding.26, 27 During trauma processing, the Broca’s area of the brain, which is responsible for putting thoughts, feelings, and memories into words, shows a decrease in activity.28 Music can bypass the verbal processing of the brain and provides direct access to emotions and memories stored in the limbic system. Therefore, it is not surprising that research suggests that people engaged in a therapeutic relationship are more open to sharing their stressful symptoms.16,18, 20, 29
For this reason, music therapists use the therapeutic process, practice within psychotherapeutic frameworks, and understand the neural mechanisms of music processing and production. Moreover, the neurologic foundations of music production and perception aids in the clinical decision-making process of music therapists in selecting and implementing music-based experiences to address the clinical needs within music therapy sessions. This knowledge informs how music characteristics are delivered to activate specific neural regions to address needs within the moment. In addition, music therapists deliver music interventions within specific theoretical orientations, as this influence when music and verbal processing occur in the treatment of specific PTSD symptoms and associated needs of depression and anxiety.19,30
Music Therapy Research with Military Populations
Research on music therapy with military populations found drumming,31,32 improvisation on multiple instruments, deep breathing, and singing,20,33,34 provide grounding, safety, and stabilization at the onset of sessions to promote presence and prepare for emotional expression of uncomfortable feelings and/or processing of traumatic events26,33 on self-selected instruments.17
Emotional expression through drumming allows for rage and release through the somatic experience of playing loud dynamics,26 regaining a sense of control through spontaneous creativity of more complex rhythms,26 and improvising uncomfortable emotions that surface.33 Songwriting provides space to voice fragmented aspects of self, identity, and unpack personal narratives within the songwriting process.35 Music therapists assist songwriters to affirm or construct identity and integrate musical styles congruent with their musical identity to reconnect with their socio-cultural identity.36 Performance of music allows for reconnections with the community as a mechanism of growth and agency within the recovery process through the expression of personal narrative to others,16 and validating expression of inner-self while feeling connected to the audience.37
Department of Veterans Affairs (VA)
Music therapists function as part of interdisciplinary teams and delivery therapy in inpatient, outpatient, and home-based settings via telehealth settings. 38, 39 In addition, music therapists throughout the VA healthcare system implement evidence-based practices in the treatment of Veterans recovering from service-related injuries.38 Treatment outcomes for Veterans receiving care at VA Medical Centers (VAMCs) indicate that music therapy can enhance the quality of life and improve functioning,31 decrease pain, anxiety, and depression,39 improve self-regulation when faced with difficult emotions,33 reduce symptom clusters of PTSD, and promote functional rehabilitation.30
The number of MT-BCs employed in VAMCs across the U.S is growing as programming continues to standardize. In 2019, the VA reported 73 music therapists working in 49 VA Medical Centers.31 To request a music therapy referral, ask your primary care provider, case manager, or interdisciplinary team members. If there is no music therapist on staff, obtain a music therapy referral and contact the Patient Advocate to identify an MT-BC through the Community Care Network of Providers.44
The Creative Forces®: NEA Military Healing Arts Network is an initiative of the National Endowment for the Arts in partnership with the U.S. Departments of Defense and Veterans Affairs. Creative Forces supports telehealth efforts that connect music therapists with Veterans in rural and remote places.43 Veterans receiving care at the VAMCs listed below are eligible to seek a referral for music therapy services, many of which offer telehealth.
Creative Forces clinical sites offering telehealth to Veterans receiving care at these VA Medical Centers, in alphabetical order by state.
- James A. Haley Veterans’ Hospital, Tampa, FL
- North Florida/South Georgia Veterans Health System, Gainesville, FL
- Richard L. Roudebush VA Medical Center, Indianapolis, IN
- Carl A. Nunziato VA Clinic, Youngstown, OH
- V. Sonny Montgomery VAMC, Jackson, MS
Department of Defense (DoD)
The DoD added music therapy to the four-week intensive outpatient program at the National Intrepid Center of Excellence (NICoE) at Walter Reed National Military Medical Center (WRNMMC) for active duty Service Members (SMs) in 2012.34 Music therapists at the NICoE assist in identifying existential and often internalized feelings/emotions, and in externalizing existential trauma to address goals of emotional regulation.40 This interdisciplinary model of care combines traditional rehabilitation therapies with integrative medicine, including music therapy, art therapy, and dance/movement therapy. A study of Active-Duty SMs in this program confirmed statistically significant and clinically meaningful improvements in a range of symptoms.40
This model has expanded to Intrepid Spirit Centers (ISCs) within military treatment facilities throughout the U.S. Within each ISC, music therapy is positioned as a standard of care,41 incorporating music therapy protocols within individual and group sessions34,42 that address specific needs of SMs related to traumatic brain injury, psychological stress, and trauma.
Creative Forces supports music therapy services at ISCs and military treatment facilities, as listed below.43
- Joint Base Elmendorf-Richardson (JBER), Anchorage AK
- National Intrepid Center of Excellence (NICoE) at Walter Reed, Bethesda, MD
- Marine Corps Base Camp Lejeune, Jacksonville, NC
- Fort Hood, TX
- Fort Belvoir, VA
- Warrior Recovery Center, Fort Caron, CO
Music Therapy Agencies and Nonprofits Serving Military Populations and First Responders
SMs and Veterans who do not have access to DoD or VA music therapy programs have an alternative in community-based programs, often initiated by Veterans, that provide opportunities for music engagement. Since many Veterans now serve as First Responders, and many First Responders (Veteran or civilian) have similar trauma symptoms paralleling SMs and Service Members, it is only fitting that these nonprofit services expand to meet both groups’ needs. Music therapy nonprofits that provide treatment to Veterans, Active-Duty SMs, and First Responders, are listed below.
Challenge America (https://www.challengeamerica.com/music-therapy)
Challenge America offers weekend music therapy retreats, focusing on PTSD treatment with Active Duty SMs and Veterans throughout the country. Retreats are facilitated by a board-certified music therapist who partners with local songwriters so each participant can create an original song. Click the link for upcoming retreats.
Metro Music Therapy (Atlanta, GA) https://metromusictherapyga.com/atlanta/mt-with-veterans/
Metro Music Therapy provides in-person and telehealth music therapy services for Active-Duty SMs and Veterans with PTSD, traumatic brain injury, military sexual trauma, and other military service-related traumas. Metro Music Therapy partners with local and national Veterans organizations to increase access to music therapy services to Veterans in Atlanta, GA.
Music Therapy of the Rockies (https://musictherapyoftherockies.org/programs/music-therapy-retreats/)
Music Therapy of the Rockies (Roarking Fork Valley, CO) offers weekend music therapy retreats throughout the country to address the symptoms of PTSD, at no cost to Veterans and Active Duty SMs. The retreats focus on the neurologic aspect of PTSD with the goal of making lifelong changes and reduce suicidality. Retreats are facilitated by a board-certified music therapist who partners with local songwriters so each participant can create an original song. Click the link for upcoming retreats.
Resounding Joy (https://resoundingjoyinc.org/music-therapy-for-all/ )
Community Connections, based in San Diego, CA, provides music programs to first responders to manage stress.
Semper Sounds Military Music Therapy (https://resoundingjoyinc.org/semper-sound/ )
Semper Sounds Program (San Diego, CA and Chelsea, MA) provides individual and group music therapy services at military bases and Veteran facilities. It offers bi-weekly drumming, songwriting, and jam sessions to Veterans and Active Duty SMs stationed at, or living near San Diego, CA., and The Soldiers’ Home Chelsea, MA.
Valor Therapeutics (Dayton, OH) (https://valortherapeutics.org/index.html)
Valor Therapeutics (Dayton, OH) offers music therapy and art therapy individual and group sessions at no cost to Veterans, Active Duty SMs, First Responders, and Military Families. Valor Therapeutics aims to reduce symptoms of PTSD and improve the emotional, cognitive, and psychological health of our nation’s defenders residing in and around Dayton, OH.
Music Nonprofits Serving Military Populations
Community-based music programs, often initiated by Veterans, that provide opportunities for music engagement for Veterans and Active Duty SMs are listed on Operation We Are Here (https://www.operationwearehere.com/musictherapy.html ) .
How to Make a Music Therapy Referral
Board-Certified Music therapists are trained healthcare providers who assess and treat psychological, behavioral, emotional, cognitive, and interpersonal factors using music. A background in music is not necessary to benefit from music therapy. To make a referral, contact your primary care manager, behavioral/mental health provider, the patient advocate at the VA through the Community Care Network, or contact the Certification Board for Music Therapists at www.CBMT.org to find a music therapist near you. If you would like to learn more about music therapy, contact the American Music Therapy Association at www.MusicTherapy.org.
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- McPherson, T., Berger, D., Alagapan, S. and Fröhlich, F. Active and passive rhythmic music therapy interventions differentially modulate sympathetic autonomic nervous system activity. Journal of Music Therapy. 2019, 56(3): 240-264.
- Chen, S.C., Yeh, M.L., Chang, H.J. and Lin, M.F. Music, heart rate variability, and symptom clusters: A comparative study. Support Care Cancer. 2020, 28(1): 351-360.
- Hakvoort, L., de Jong, S., van de Ree, M., Kok, T., Macfarlane, C. and de Haan, H. Music therapy to regulate arousal and attention in patients with substance use disorder and posttraumatic stress disorder: A feasibility study. Journal of Music Therapy. 2020. 57(3): 353-378.
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