66823 • Incorporating Musical Strategies into Clinical Practice

Table of Contents

66823 • Incorporating Musical Strategies into Clinical Practice

How to Receive Credit

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planner

Division Planner Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. FOUNDATIONS

HISTORICAL AND CULTURAL CONTEXT

DEFINING MUSIC

MUSIC AND THE BRAIN

3. THE THREE-STAGE CONSENSUS MODEL OF TREATMENT

STAGE 1: USING MUSIC FOR STABILIZATION

STAGE 2: USING MUSIC FOR PROCESSING/WORKING THROUGH PAST MATERIAL

STAGE 3: USING MUSIC IN THE REINTEGRATION (RETURN TO OPTIMAL FUNCTIONING) STAGE

INCORPORATING MUSIC INTO TELEHEALTH SERVICES

4. CONCLUSION

5. RESOURCES

BOOKS

WEBSITES

Works Cited

66823 • Incorporating Musical Strategies into Clinical Practice

Jamie Marich, PhD, LPCC-S, REAT, RYT-500, RMT

www.netce.com

Copyright © 2023 NetCE, All rights reserved.

Music has been a centerpiece of the human experience for thousands of years. Music is a critical part of celebrations and rituals all over the world, and most people would feel lost, on some level, without some type of music in their lives. An understanding of the neurologic response to psychotherapy will allow clinicians to bring music into the therapeutic process to unify the components of the triune brain. In addition to elucidating some of the foundations of music and the brain, this course will offer numerous practical strategies that can be incorporated into all facets of treatment: initial stabilization, processing/working through past material, and helping clients return to optimal functioning.

66823 • Incorporating Musical Strategies into Clinical Practice

Education Category. Psychiatric / Mental Health

Release Date. 04/01/2023

Expiration Date. 03/31/2026

How to Receive Credit

To complete this course for continuing education credit please go to http://www.netce.com/course/2583 in your browser.

For assistance with receiving continuing education credit, please contact us at help@netce.com.

Course Overview

Music has been a centerpiece of the human experience for thousands of years. Music is a critical part of celebrations and rituals all over the world, and most people would feel lost, on some level, without some type of music in their lives. An understanding of the neurologic response to psychotherapy will allow clinicians to bring music into the therapeutic process to unify the components of the triune brain. In addition to elucidating some of the foundations of music and the brain, this course will offer numerous practical strategies that can be incorporated into all facets of treatment: initial stabilization, processing/working through past material, and helping clients return to optimal functioning.

Audience

This course is designed for psychologists, especially because music holds special meaning for so many of the people that are served by this profession. This course will be especially relevant to professionals who seek creative methods for working with their clients.

Accreditations & Approvals

Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs. NetCE is recognized by the New York State Education Department's State Board for Psychology as an approved provider of continuing education for licensed psychologists #PSY-0240. This course is considered self-study by the New York State Board for Psychology.

Designations of Credit

NetCE designates this continuing education activity for 5 credit(s).

Course Objective

The purpose of this course is to demonstrate how simple musical strategies can be incorporated into various treatment settings in order to enhance the overall healing process.

Learning Objectives

Upon completion of this course, you should be able to:

1. Discuss the historical and cultural roles of music and its impact on human healing.

2. Describe the basics of how music affects the human brain.

3. Explain the three-stage consensus treatment model.

4. Evaluate the use of musical techniques/approaches in the stabilization stage of treatment.

5. Analyze the use of musical techniques/approaches in the processing stage of treatment.

6. Outline the role of musical techniques/approaches in the reintegration stage of treatment.

Faculty

Jamie Marich, PhD, LPCC-S, REAT, RYT-500, RMT, (she/they) travels internationally speaking on topics related to EMDR therapy, trauma, addiction, expressive arts, and mindfulness while maintaining a private practice and online education operation, the Institute for Creative Mindfulness, in her home base of northeast Ohio. She is the developer of the Dancing Mindfulness approach to expressive arts therapy and the developer of Yoga for Clinicians. Dr. Marich is the author of numerous books, including EMDR Made Simple, Trauma Made Simple, and EMDR Therapy and Mindfulness for Trauma Focused Care (written in collaboration with Dr. Stephen Dansiger). She is also the author of Process Not Perfection: Expressive Arts Solutions for Trauma Recovery. In 2020, a revised and expanded edition of Trauma and the 12 Steps was released. In 2022 and 2023, Dr. Marich published two additional books: The Healing Power of Jiu-Jitsu: A Guide to Transforming Trauma and Facilitating Recovery and Dissociation Made Simple. Dr. Marich is a woman living with a dissociative disorder, and this forms the basis of her award-winning passion for advocacy in the mental health field.

Faculty Disclosure

Contributing faculty, Jamie Marich, PhD, LPCC-S, REAT, RYT-500, RMT, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planner

Margaret Donohue, PhD

Division Planner Disclosure

The division planner has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

As humans, some of our most profound memories are associated with music—the song played at a wedding, the music popular when you were in high school, songs that you sang as a child, songs taught by a parent, a special relative, or a school teacher. On the other hand, not all musical associations are positive. If a marriage eventually fails, feelings of sadness or disgust may be elicited when one hears the song that played at their wedding. Hearing a song that was special to a deceased loved one can lead to tears upon the first several notes. Someone who was an unpleasant or traumatic person may have always listened to a certain band, song, or style of music, and hearing that music today may elicit a negative response.

Music plays a powerful role in accessing our memories and connecting to the deepest states of emotional expression. Few people who have some experience with the power of music, either as a musician or as a listener, would question the relevance of this statement. Because music plays such a powerful role in the human experience, it can be beneficial to take greater measures to integrate it into the helping processes. Incorporating music into clinical practice can enhance what you already do, and it is not necessary to obtain special training as music therapists. If one has an ability to tap into what music means to him/her personally and a passion for helping others, learning a few simple strategies within the trauma-sensitive model of treatment will allow the healing power of music to enhance clinical efficacy and ultimately benefit clients.

2. FOUNDATIONS

HISTORICAL AND CULTURAL CONTEXT

Reflection

Without overthinking, take a few minutes to write down how you would define music. Is it difficult for you?

German poet Heinrich Heine once wrote about music, "When words leave off, music begins" [1]. Indeed, most people find it difficult to describe what music is in words. The reality of experiencing music calls upon connections in the brain that have nothing to do with words. For those who believe in the spiritual or mystical capacities of music, the reasons that words cannot adequately be used to define it are even more salient.

DEFINING MUSIC

Defining music may seem very basic. However, in the spirit of education and inquiry, consider a few linguistic attempts to define music.

Random House Dictionary defines music as, "an art of sound in time that expresses ideas and emotions in significant forms through the elements of rhythm, melody, harmony, and color" [18]. Wikipedia indicates that music is "an art form and cultural activities whose medium is sound organized in time. The common elements of music are pitch, rhythm, dynamics, and the sonic qualities of timbre and texture" [19]. Etymologically, the word "music" is derived from the Greek mousike techne, meaning art of the muses. Another Greek derivation is mousikos, meaning of or pertaining to the muses.

The purpose of this course is not to provide an overview of music terminology and theory. However, the first two examples show that, in a technical sense, defining music requires proficiency in other terminology, terms like pitch, tone, and timbre, that serves as the basis of what we appreciate in the end product as music. The etymologic derivation of the word music suggests a spiritual or mystical quality that many have been ascribed to music over the years, and for those who consider a focus on the technique of music distracting or simplistic, embracing the word origin as a means of definition may seem more suitable.

Honoring Individual Music Tastes

As with many constructs in the subjective human experience, defining or describing music will depend on the individual. Consider what music scholar Daniel J. Levitin posited regarding this idea [2]:

What is music? To many, "music" can only mean the great masters—Beethoven, Debussy, and Mozart. To others, "music" is Busta Rhymes, Dr. Dre, and Moby. To one of my saxophone teachers at Berklee College of Music—and to legions of "traditional jazz" aficionados—anything made before 1940 or after 1960 isn't really music at all.

This is perhaps best illustrated by generational differences in popular music tastes. The clichéd notion that the music "kids these days" listen to is "just noise" has been perpetuated for decades.

Perhaps the ability that humans have to receive and appreciate music in so many different ways is part of what makes it so powerful, especially considering how it can be used in the healing process. One of the principles of counseling and healing is the art of being able to meet people where they are in their subjective experiences upon entering the clinical process, and honoring the musical tastes and proclivities of that individual may be one way to meet a person on the road of his or her journey.

Music in Global Cultures

Reflection

Think about your cultural background or how you were raised. What role does/did music play in your culture or in your way of life?

As Levitin states, "Mothers throughout the world, as far back in time as we can imagine, have used soft singing to soothe their babies to sleep, or to distract them from something that has made them cry" [2]. Music is a true cultural universal, an aspect of the human experience that is present in every culture in some form. Although music may carry different meanings and be performed or used differently among the various cultures of the world, every culture regards music or sound as significant [17]. Arguably, language, eating, and sex are the only other facets of the human experience that are true cultural universals, and these activities are required to continue the human species. It is interesting that music is as universal as these activities, which is a major reason why helping professionals can benefit from incorporating this powerful entity into the healing process.

Although providing a comprehensive treatise on the role that music plays in specific world cultures extends beyond the scope of this course, professionals are encouraged to investigate it more if it is of interest or if music will be incorporated into practice. If a client identifies strongly with a specific cultural heritage, seeking more information about the role of music in that culture may be helpful. Resources for additional research are included at the end of this course.

Music in the Healing Process

In her classic autobiographical tale Gather Together in My Name, writer Maya Angelou credits the power of music in her healing process [3]. She states, "Music was my refuge. I could crawl into the space between the notes and curl my back to loneliness." Indeed, many great musicians began as children who were awkward, traumatized, or otherwise unable to integrate their experiences with others around them and who sought music as a refuge for loneliness.

MUSIC AND THE BRAIN

Throughout the centuries, the idea that music can somehow pick up or take over where the spoken word leaves off or cannot reach has been prevalent. This conveys an essential truth about the human brain: it is not just a verbal instrument, and it is certainly not just a cognitive instrument. In fact, the brain is capable of processing information in such a variety of ways, it is important to consider how music can play a role in helping humans to process and express what words cannot.

To further the role of processing, it is vital to review some theories of basic psychology. MacLean's triune brain model suggests that the human brain actually operates as three separate minds, each with its own role and its own respective senses of time, space, and memory [4]. While this model's use in terms of neuroanatomic evolution is considered by some to be outdated or oversimplified, it is useful as a purely explanatory tool. It describes the brain structure in a manner that is easy to understand and use as a conceptualization for treatment planning:

- The R-complex brain (reptilian brain): Includes the brainstem and cerebellum. It controls reflex behaviors, muscle control, balance, breathing, and heartbeat and is very reactive to direct stimulation.

- The limbic brain: Contains the amygdala, hypothalamus, and hippocampus. It is the source of emotions and instincts within the brain, including attachment and survival. When this part of the brain is activated, emotion is activated. According to MacLean, everything in the limbic system is either agreeable (pleasure) or disagreeable (pain/distress), and survival is based on the avoidance of pain and the recurrence of pleasure.

- The neocortex (or cerebral cortex): Contains the frontal lobe and is unique to primates. The more evolved part of the brain, it regulates executive functioning, which can include higher order thinking skills, reason, speech, meaning, and sapience (e.g., wisdom, calling on experience).

Humans rely on all three brains to function. Thus, optimal processing of information would require all three brains to harmoniously operate to facilitate this essential processing. In music, the term harmony means, "the sounding of two or more musical notes at the same time in a way that is pleasant or desired" [5]. In contrast, multiple sounds being made at the same time out of harmony can sound like a cacophony or sheer racket. As with musical harmony, if the three brains of the triune brain are not working together, an unpleasant effect can occur. In individuals with unresolved trauma or other negative experiences, the limbic brain may be dominant, drowning out the other brain functions that may need to be heard in order for harmony to result.

Cognitive therapies are designed to activate and work with higher order thinking. However, for clients who have unprocessed trauma symptoms, the three brains are not fully communicating. During periods of intense emotional disturbance, the functions of the frontal lobe cannot be optimally accessed because the limbic brain, or "survival brain," is in control [6,7]. Moreover, if a person is triggered into a fight, flight, or freeze response at the limbic level, one of the quickest ways to alleviate that pain after the distress is to feed the pleasure potential in the R-complex. Alcohol, drugs, food, sex, gambling, shopping, hoarding, or other reinforcing activities are particularly effective at managing the pain [8].

Traumatized individuals are often stuck in a survival mode. The limbic region of the brain is activated during the original trauma to help the traumatized person survive. Because the left and right frontal lobes are abandoned during the experience (resulting in awareness but lack of ability to process), the individual is never able to link the limbic activation to the frontal lobe. Thus, in developing treatment plans for traumatized individuals, using cognitive strategies that primarily target the frontal lobe may not be effective.

One reason trauma may remain unprocessed is due to a misunderstanding of what processing involves. In many Western cultures, clinicians tend to assume that talking is the best way to process trauma; however, in other cultures, approaches can vary from spiritual interventions to physical treatments. In many mental health and addiction treatment settings in the United States, talking is synonymous with processing. Although talking can help a person process, it is primarily a function of the frontal lobe. A person can talk about the trauma extensively, but until it is addressed at the limbic level, the trauma will likely remain a problem [9]. Experiential modalities, like music, are more likely to address limbic-level activity when compared to the classic "talking it out" strategies [9].

Music activates the physiologic systems of the body from the cognitive level of the brain down to the visceral level [10]. Music, by its design, unifies the triune brain, thus promoting a sense of harmonious integration. The primary reason for this unification is that the coming together of rhythm and melody bridges the primitive brain with the neocortex, the part of the brain responsible for higher level executive functioning [2].

Neuroanatomic studies reveal significant physical changes in major brain structures as a result of trauma. When untreated, these important structural alterations cause the symptoms of PTSD. Traumatic and chronic stress creates lasting changes in three important brain areas: the amygdala, hippocampus and prefrontal cortex [20,21].

Properly applied, therapeutic interventions can stop the cycle of hyperarousal and fear by forming new pathways in the brain. Music can be a useful part of treatment for clients who have experienced trauma, as t produces neuroplasticity and neurogenesis. Music directly stimulates the amygdala, causing a normalizing effect for processing stimuli—such as interpreting the significance of faces, sounds, and voices. The amygdala network regulates social interactions by regulating the approach to new situations and the appropriate withdrawal from them.

Musical compression waves also stimulate the hippocampus to regulate cortisol levels. In addition, music stimulates the reward pathway, which releases dopamine [22].

Levitin explains the significant role that music plays in the brain of the developing child, a phenomenon that he identifies as a cultural universal [2]. Music's function in the developing child is to help prepare the mind for a number of complex cognitive and social activities. For the developing brain, music is a form of play, an exercise that invokes higher level integrative processes that nurture exploratory competence, preparing children to eventually explore generative language development. A cultural universal that Levitin addresses is that of the mother singing to her child, noting that early, healthy mother-child relations often involve music (e.g., humming, lullabies). Moreover, these interactions are almost always accompanied by a rhythmic movement. According to Levitin, when vision, hearing, and movement work together "the infant lives in a state of complete psychedelic splendor" [2]. Music provides integration at the level of the brain that is concomitant with the healing process that we strive to promote as part of psychotherapy.

3. THE THREE-STAGE CONSENSUS MODEL OF TREATMENT

For those who treat problems related to traumatic stress, treatment is typically approached as a three-phase process [11,12,13,14]. The stages of this three-stage consensus model of trauma treatment are:

- Stabilization or preparation: Working with clients to address their acute symptoms and developing a series of coping skills and other affect-regulation strategies for the purpose of distress tolerance

- Working through the trauma: Using a therapeutic approach or a series of therapeutic approaches and other supportive strategies to process the traumatic memory or memories and their impact, with the ultimate goal of resolution that leads to improved life functioning

- Reintegration/reconnection with society: Assisting the client to take the gains made during stabilization and working through the trauma and apply them to the improvement of life functioning, social interactions, and personal well-being

Trauma is defined in many ways, but it is important to remember that it is a noun; it refers to an actual experience or wounding. Often, clinicians describe trauma based on its effects, not the actual experience. The word "trauma" is derived from the Greek word that literally means wound. By considering what physical wounds are and how they affect humans, the meaning of emotional trauma may be further understood.

Emotional traumas also come in various shapes and sizes, resulting from many possible causes. For some, a simple trauma (wound) can clear on its own, but for others with more complex emotional variables, the healing process may take longer. If a traumatized individual does not obtain the proper conditions to heal, it will likely take longer for the trauma to resolve. In the meantime, other symptoms can manifest.

Operational definitions of trauma, as officially supported by the psychologic professions, are also useful. According to the American Psychological Association's Dictionary of Psychology, trauma is [15]:

An event in which a person witnesses or experiences a threat to his or her own life or physical safety or that of others and experiences fear, terror, or helplessness. The event may also cause dissociation, confusion, and a loss of a sense of safety. Traumatic events challenge an individual's view of the world as a just, safe, and predictable place.

Helping professionals continue to debate whether certain types of trauma are "worse" than others. For instance, this definition goes on to propose that traumas caused by humans (e.g., rape, assault) often result in greater psychologic impact than those caused by nature (e.g., earthquakes, floods) [15]. Others, however, assert that trauma caused by people may be worse for certain people, depending on an individual's situation, constitution, and overall coping system in place to deal with the trauma. Because the human experience of trauma is fundamentally subjective, comparing traumas is difficult and generally not helpful.

It may seem odd to introduce a trauma treatment model into a course about incorporating music into the therapeutic process. However, this consensus model can be applicable to other disorders treated clinically in which some type of trauma plays a role in the development of the disorder. The model also offers a framework through which music can be incorporated into the therapeutic process in each of the three stages, depending on the individual needs of the client.

Another helpful construct to consider is that of complicated grief. First proposed by Helene Deutsch, a colleague of Sigmund Freud, complicated grief (or masked grief) refers to the experience of maladaptive or problematic psychologic symptoms that can be traced back to unresolved grief. Unexplained physical symptoms can also be attributed to a masked grief reaction [16]. As with unresolved trauma, music may help with coping, working through the complications, and helping the client to reintegrate when complicated or masked grief prevents him or her from optimally functioning in life. Throughout the course, many of the suggestions proposed for helping with unresolved trauma can be applied to unresolved grief, and vice versa.

STAGE 1: USING MUSIC FOR STABILIZATION

As noted, stabilization (also referred to as preparation) consists of working with clients to address their most acute symptoms and developing a series of coping skills and other affect-regulation strategies for the purpose of distress tolerance. In applied terms, a client is not expected to confront all of his or her problems on the first day of treatment, so it is important for the client and clinician to develop a series of strategies that can be used for coping, stress tolerance, and affect regulation. These skills do not have to be developed perfectly but practiced reasonably enough so the client will have healthy ways to self-soothe and cope when therapy becomes more intense. The following examples illustrate how musical strategies can be worked into the arsenal of coping skills and techniques for stabilization.

Case Studies

Case Study 1

Client A is a woman, 34 years of age, who is a survivor of extensive childhood sexual abuse. She presents for outpatient treatment, specifically to address unresolved issues that have affected her interpersonal functioning for years. Client A, a self-identified lesbian, recently got out of a manipulative relationship with a long-term partner, and she finds herself contemplating another equally dangerous relationship at the time that she presents for counseling. Client A has been recommended for eye movement desensitization and reprocessing (EMDR) therapy, a specialty treatment to address her post-traumatic stress disorder (PTSD). However, her therapist discovers that attempting EMDR immediately may be a bit of a problem because Client A has a difficult time visualizing, especially using visualization to develop safe coping resources. During the initial intake sessions, Client A reports that she is a lover of music, especially jazz music. She also indicates that although she struggled over the years with connecting with anything spiritual (primarily because her father was a member of a fundamentalist religious denomination and some of her sexual abuse occurred on the grounds of a school run by that denomination), listening to music is the closest she has come to meditating or "being spiritual."

In preparation for the more extensive therapy, her therapist asks if there are any specific songs that Client A feels are calming or empowering. After scanning her memory, she identifies one song that has both properties for her: "O-o-h Child" by the Five Stairsteps. With an empowering melody and a positive, future-oriented message of hope and healing, Client A and her therapist decide that this is an excellent song for her to use as part of her stabilization plan. The therapist obtains a copy of the song, and they listen to the song together in the office. Client A's therapist invites her to close her eyes if she feels comfortable, and she elects to do so. As the song progresses, a smile washes over her face, and when the song is over, Client A verbalizes, as best she can, how much calmer her body felt by really focusing on the song.

Client A reports that she has a copy of the song on her portable music device, so she is able to access it on her own if needed. Client A and her therapist agree that they will have this song ready to use to calm Client A at the end of a session if their exploration of her traumatic stress issues using the EMDR process becomes too disturbing for her.

Case Study 2

Client B is a man, 42 years of age, presenting to a new therapist after spending most of his adult life in the community mental health system. Having received a variety of diagnoses over the years, Client B's previous therapist concurred that he needed to be seen by a counselor who was trauma-sensitive, as he is having trouble processing the various abuses and losses he experienced as a younger man. When he presents for therapy, knowing that hypnotherapy, EMDR, and several other specialty interventions for trauma are available, he cautions the therapist, "I can't relax. Other therapists have tried, but I just cannot relax." When the therapist asks him what other methods he has used, he reports that it was mostly guided imagery and breathing. During the first session, shortly after issuing this warning, Client B's cell phone rings, sounding out a popular country music song. This spawns a productive discussion about his musical tastes, and the therapist asks the client if he is willing to experiment with sound and musical strategies to help him relax. Client B is excited to try this approach.

Client B begins by identifying a series of Christian music songs that he finds inspirational and peaceful. The therapist is able to access these songs online and starts to play one over her computer's speakers. She invites him to stay focused only on the song and to let himself relax. It takes some practice, but soon Client B is able to bring his focus back to the song when his thoughts begin wandering. After each song-based meditation, Client B and his therapist are able to discuss the feelings and body sensations that the song elicited.

Upon witnessing how responsive Client B is to sound, the therapist decides to implement a Tibetan singing bowl as a form of mindfulness meditation. Client B is invited, upon hearing each long, echoing cling of the bowl, to be mindfully aware of the sound. He reports that he finds this process extremely relaxing. Several sessions later, when Client B and his therapist agree that he is ready to explore some of his past issues with hypnotherapy, the Tibetan singing bowl and Client B's mindfulness practice are incorporated to help induce a state of hypnosis.

Case Study 3

Client C is a young woman who recently entered recovery from alcohol and opioid addictions. Although she presents for treatment and begins attending 12-step meetings with a solid sense of awareness that she has a problem, she is still struggling to manage her cravings in an effective manner. Her sponsor and her counselor have told her that any craving, or any negative feeling, will eventually pass, but it is up to her to identify an effective coping mechanism to deal with the moments when these feelings are strongest. Always a fan of music, Client C finds that playing a song she finds to be comforting and inspirational on a steady loop seems to help the negativity pass. In some cases, she plays one particular song 20 times. Often, she sings along, but at other times, she simply listens and allows the words and melody to absorb her. Even after five years of sobriety, Client C finds this "musical looping" strategy to be incredibly effective to help her manage triggers and thoughts of acting impulsively.

Reflection

Think of a song or series of songs that help you feel relaxed, empowered, or rejuvenated. What is it about the song that is special to you, and what are the words you can use to describe how that song makes you feel? If possible, spend the next several minutes mindfully connecting with the song. If your thoughts should drift elsewhere, bring them back to the song and stay mindfully aware of your listening experience.

Using Music in Guided Imagery

Not everyone is able to do guided imagery. This makes sense because not everyone is visually inclined. Yet in the culture of therapy, guided imageries are often the first or preferred relaxation strategy. If visually oriented guided imagery exercises are not working for a client, accessing imagery or relaxation through music can be an alternate strategy.

Almost any classic guided imagery exercise can be replaced with a piece of music. A classic example is the calm place (sometimes referred to as "safe place" or "happy place") exercise. In a calm place imagery, clients are typically asked to tell the therapist about a place they have been, a place they would like to go, or a place where they have only been in their imaginations that helps them feel calm. If a client cannot come up with anything, then the therapist typically suggests one of his or her own guided imageries, like a soothing beach or a tranquil forest. Then, the therapist will break down the image and invite the client to focus on various facets of it, like the blueness of the water in the ocean. Other senses may be incorporated, like listening to the waves on the beach or hearing the wind blow through the trees.

The point of these exercises is to get clients to use their own senses of imagination to experience a healthy, soothing escape from the stressors of life. By the end of an imagery exercise, if clients report feeling relaxed, then therapists typically interpret this to mean that the exercise went well. However, some clients simply will not be able to get relaxed. In these cases, the "image" in guided imagery can be replaced with a song or a series of sounds. This can involve cuing up a recording of a sound sample that the client has identified as positive (e.g., children laughing, waterfalls) or a whole song that the client has identified as positive. When the sound clip or song is played, invite the client to just listen, simply noticing the sound/song. If, while listening to the sound or song, the client's attention appears to be drifting, invite the client to draw his or her focus back to the song, noticing any feelings or sensations that the sound or song is bringing up in the body.

After the sound or song has ended, take a moment to invite the client to just be with the silence and notice anything that might be coming up (e.g., body sensations, feelings, thoughts, memories) after listening to the song. What emerges from the experience of listening to the song can be used in the therapeutic process. Hopefully, the listening experience will have provided a positive, soothing experience for the client, but if for some reason it did not, information about what it did elicit can be used to better understand the client's experiences and how he/she may process music or sound. In cases in which listening to a piece of music brings up negative feelings (as any guided imagery may), spend a few moments verbally processing those feelings with the client, and then decide if the client wants to attempt another sound or song. In some cases, what the client thought would be a positive sound experience is not, but a different sound resource may be more positive.

This exercise can be taken a step further by adding a "cuing" component. With any resource-building activity used in stabilization, it is typically not enough to use a positive exercise like a guided imagery or musical guided imagery without putting it to the test. With cuing, the client is asked to bring up a negative stressor or stimulus (typically avoiding major traumas during this stabilization process). If the negative stimulus has a sound that goes along with it (e.g., the screeching of a voice, the thump of files being dropped onto a desk at work), invite the client to notice that stressor. After the client spends a few moments with the stressor, ask where he or she most feels or experiences the stressor and see if he or she can describe it (e.g., a tight knot in the stomach, pinching needles in the shoulders). Then, play the positive sound clip or song and invite the client to engage in the same reflective process. Invite the client to focus only on the sound or song, steering attention as best as possible away from the stressor or negative body reaction. After the sound exercise is complete, ask the client what happened to the body sensation. If the musical exercise worked, the negative body experience will have been replaced with something more positive or significantly diminished in intensity.

The next step is to begin with the body cuing of the stressor (or another stressor for this next phase of the exercise) and then, instead of playing the song, invite the client to simply bring up the sound or song in his or her head without directly playing it. If clients can learn to recall the song in order to address the negative effects of the stressor, this will give them a coping strategy to use even if they are in a position in which they cannot easily get to a device that plays music.

Another variation is to use the sound clips or piece of music together with a guided imagery. Some clients who respond to guided imagery find that sounds or pieces of music in the background give the imagery additional impact. Whenever possible, the sounds should match the imagery (e.g., waves for a beach image, chanting or religious music for a religious scene). One may also use theta wave music. Any calming music that is typically marketed for meditation or yoga may work to help enhance guided imageries, and most of these recordings make use of rhythms or vibrations that are able to stimulate theta wave activity in the brain, the frequency at which a brain is most likely to enter into a drowsy or hypnotic state. Adding these calming, meditative sound patterns or pieces of music while you are working on a guided imagery exercise can be beneficial to the client.

Music Relaxation to Improve Sleep Quality

Relaxing and calming music listening can, furthermore, be helpful to improve sleep and also to reduce depression. Insomnia and recurrent nightmares are common symptoms of PTSD, anxiety, and depression. One study investigated two nonpharmacologic approaches to treatment for clients with PTSD—progressive muscular relaxation and music relaxation [23]. Music relaxation was found to significantly reduce depression and increase sleep efficiency, with improvements in sleep latency, sleep activity, and wake episodes. In addition, sleep efficiency was highly correlated to reduction in depression scores. The music composed for the study featured a slow, repeated melody on piano with background violins and bells.

Making a Playlist

The term playlist is a relatively new addition to the English lexicon, popularized by the advent of mp3 players and other electronic musical storage devices. Listeners are less likely to listen to an entire album and instead tend to make a customized list of songs that they can access at any time for listening. A playlist can be a good adjunct to the therapeutic process, because a client can work to make, with or without assistance, a list of songs to meet a specific therapeutic need at any given moment. Even if a client does not have a portable music device, playlists can be burned to a CD. Helping navigate the technology aspect of music aggregation may be necessary for some clients.

Playlists can typically be made using a series of songs that flow along the following themes:

- Soothing/calming

- Empowering

- Motivating

If a client is about to encounter a potentially stressful experience in life, it would be advisable to bring up the soothing/calming playlist. If a client is going to take a very important test for work or school and struggles with low self-confidence, listening to the empowering playlist on the way to take the test may be helpful. For a client who is struggling to stay sober, listening to a motivating playlist on a daily basis could be a powerful adjunct to his or her recovery program.

Reflection

Choose one of the themes listed above (soothing/calming, empowering, or motivating) and list 5 to 10 songs or sounds that you would include on this playlist for yourself. If you want to take this exercise a step further, create and add this playlist to your portable music device or make a CD.

There are a few cautions to consider when working on playlists with clients. A major caution, especially when working with young people, relates to how you help the client screen the music on his or her playlist, as this is a very delicate process. On one hand, the client may choose songs that seem radically inappropriate for a healing exercise. For example, including a violent rap song on a motivating playlist may raise some red flags in your clinical head. However, it is important not to minimize the client's choice of song if the song carries great meaning, especially in a survival context, for the client. If a song does raise a red flag, ask the client to explain what the song means, giving him or her a chance to justify the inclusion of that song on the playlist. If concerns persist, express them in a gentle manner; this can often lead to a very good dialogue about adaptive versus maladaptive (e.g., healthy vs. unhealthy) coping strategies.

Using Music to Build a Vocabulary of Feelings

The screening conversation described in the previous section can also serve a powerful function in the area of helping a client to better explain and express feelings. When a person is asked to describe what a certain song means to him or her, it can open up a whole new conversation about coping over the years and how certain songs make him or her feel, especially in relation to life experiences.

Music can be used in a variety of ways to help clients express feelings when they may otherwise lack the vocabulary to do so. There are two major ways that this can be accomplished. First is to add the step of asking the client, assuring him that there are no right or wrong answers, to describe feelings the song induces after the musical variation on the guided imagery exercise. Again, this process may require some guidance. If a client cannot put a specific word to a feeling (e.g., sad or happy), it may help to ask, "When you listen to that song, what happens in your body?" or "You seemed very happy when you were listening to that song. Am I observing that correctly? What about the song seems to make you happy (or insert any other feeling that you might observe)?"

Secondly, one could invite the client to share feelings or experiences through music that may be difficult to express in precise words. Looking at song lyrics may provide insight into a client's feelings, and one can build off of those song lyrics to get the client not just to talk about his or her feelings, but also to take some pauses and experience them within the context of the session.

Clients who are struggling may be invited to bring to the next session a song or series of songs that best explains his or her life or current struggles. This exercise may not work for everyone, but for those clients who like music for listening pleasure, it may give them something from which to springboard when it comes to the often-daunting process of feeling exploration.

Using Music in Group Setting

Both the playlist activity and using music to build a vocabulary of feelings can be easily worked into group settings. Adolescents, who may be prone to finding treatment groups boring and repetitive, tend to react positively to sharing a song or two from their playlist with the rest of the treatment group. Engaging in group listening, an activity common in most cultures, can lead to fascinating discussions about how individuals in the group interpret the song. Productive therapeutic discussions can stem from groups listening to a song that one group member brought to the session.

The group facilitator also has the ability to do a group "vocabulary of feelings" exercise by playing a song for the group. After inviting clients to listen to the song as a group and notice the reactions that come up in their bodies upon listening to the song, a discussion can be facilitated. Group members often end up relating to each other during this process, and a group member who struggles with identifying and verbalizing feelings may be assisted by hearing other group members share. The only major caution in group work, at any stage, is to ensure the facilitator is available after the group to discuss any disturbing reactions that a client may have experienced while the song played, as clients may not feel comfortable sharing them with the whole group.

One study involving veterans with PTSD explored spontaneous drumming in a group [24]. Reductions in PTSD symptoms were observed following drumming sessions, with veterans accessing their traumatic memories in a safe way, expressing intense emotions, and regaining a sense of control. Playing music in a group offers a way to normalize focus and attention and can lead to a feeling of harmony with the group.

Clients Who Play an Instrument, Sing, or Write Songs

Of course, not all clients are musically inclined, but for those who are, there are additional options for incorporating music into the healing process. For many people with musical talents, the disorder that brought them into treatment in the first place (e.g., addiction, a mental illness, complicated adjustment) may have caused them to abandon their musical pursuits. Thus, suggesting returning to music as a coping strategy to help with stabilization can be a powerful technique. It is important to reiterate to clients that if they choose to take their instruments out again, or if they choose to sing again, it is not important that they perfect the craft, especially if they were once competent at it. Rather, tapping into the joy that can be experienced simply by playing and creating should be emphasized, encouraging the client to be gentle with him or herself during the process of rediscovery.

Songwriting can help feelings take new flight. For clients who mention that they have written songs or that they play an instrument and maybe write some poetry, ask if they have ever considered writing music as part of their therapy. Again, emphasize that it does not need to be perfect. If it is emotionally pure and can help with coping, it can be used as part of stabilization.

One study explored the role of songwriting in veterans with PTSD [25]. In this study, clients wrote songs about their combat experiences, then listened to the song daily for four weeks. At the end of the study, there was a 33% decline in PTSD symptoms and a 22% decline in depression symptoms.

STAGE 2: USING MUSIC FOR PROCESSING/WORKING THROUGH PAST MATERIAL

There are several terms in the literature on trauma and psychotherapy that have been used to describe the second stage of treatment. One common term is processing, or making sense of an experience and learning. Processing can include achieving the resolution needed to move on from a traumatic experience or series of experiences. Some therapists prefer the term reprocessing, using the logic that because the traumatic experiences were never processed adaptively in the first place, then they need to be reprocessed. Reprocessing can be defined as consciously accessing an affected memory or experience and striving to bring about a more adaptive experience or resolution. This stage can be described as a working through of the trauma, or using a therapeutic approach or series of approaches and other supportive strategies to process the traumatic memory and its impact, with the ultimate goal of resolution that leads to improved life functioning.

In the mental health professions, there is an erroneous assumption made by many well-meaning professionals that working through of the trauma must include talking about it. While clients may need to work through the trauma in a properly supportive context, talking about the trauma is not necessarily what needs to happen in order for processing to take place. When one considers the triune brain model introduced earlier in this course, it is clear that the part of the brain responsible for talking and language is totally different from the part of the brain where traumatic memories are maladaptively, or problematically, stored. While talking about the trauma is not totally negative, it typically needs to be coupled with a physical or multisensory activity in order to be effective. This can include exercise, yoga, imagery, meditation or prayer, art or drawing, journaling or creative writing, or engaging in psychotherapies that are designed to incorporate the whole body (e.g., EMDR, hypnotherapy, emotional freedom technique, somatic processing, progressive relaxation, systematic desensitization, exposure therapy, psychomotor therapy, neuro-emotional technique). Musical strategies can be ideal for helping a person work through traumas or negative experiences, either by listening or creating. This section will continue to explore some powerful ways that music can be incorporated into the healing process.

Case Studies

Case Study 1

Client D is a man, 29 years of age, who enters outpatient counseling treatment. In his initial assessment, Client D reveals a series of traumas resulting from being bullied in school due to his visual learning disorders and maneuvering the household dynamics in his family of origin. Both of his parents were severe alcoholics and addicts. The client experienced a major loss at 12 years of age when his alcoholic father, who taught the client a love of music (specifically, the Beatles), died in the client's arms. These experiences have yielded problematic negative beliefs, including a need to hide emotions and a feeling of being intellectually inferior. These cognitions appear to be at the root of his depressive symptoms. Client D first manifested depressive symptoms (e.g., low motivation, hopelessness, poor energy, fleeting suicidal ideations) at 13 years of age, and they have intensified over the years as various life stressors were introduced.

Before presenting for treatment, Client D had been involved with five other counselors who were primarily cognitive-behavioral in their orientation. Client D found these treatments only minimally helpful; thus, he is willing to try alternative methods. Client D is determined to be a good candidate for EMDR, although he is unable to develop a traditional, visually based "safe place," a strategy that is often used as stabilization in EMDR treatment, which makes sense considering his history with visual learning problems. Client D responds very well to using a piece of music instead of an image.

When working through the trauma is commenced with EMDR, Client D begins blocking immediately, and his therapist is considering abandoning EMDR as an intervention. During his twelfth EMDR session, with the distress levels of his major traumas still very high, the therapist makes a decision to have a few musical tracks available (primarily music of the Beatles) that she has determined (based on her musical experience) could potentially unblock the client if he is stuck in an "unfeeling loop." During a major block in this session, the counselor chooses to play a Beatles song ("Let It Be") that was specifically meaningful to Client D's father. As he listens to the song, the client is able to cry and release feelings about his parents that he has been holding on to. At the next session, the distress levels connected to his major trauma memories (measured on Wolpe's 0–10 subjective units of distress scale) decreased by half.

Client D participates in three more traditional EMDR sessions with use of the musical interweave with no major shifts in distress levels but numerous reported improvements in depressive symptoms. Client D, who had been on extended leave from work due to his depression, is able to return to work, and he graduates from college, which he had previously thought would be impossible. Due to financial concerns, Client D elects to terminate treatment, but he feels that the treatment has helped him get to a "better, more manageable" place overall. Client D reports a general alleviation in his depressive symptoms through better expressing his feelings, with a definite improvement in self-awareness.

Case Study 2

Client E is a graduate student in psychology who presents for counseling services to fully resolve her issues of childhood sexual abuse. Although Client E has seen several counselors in the past and has engaged in a great deal of work on her own (e.g., self-help reading, journaling), she knows that there is still some material left to be resolved if she is going to help other people work on their traumatic issues. Client E admits that she is very intellectual but has difficulty expressing herself emotionally. An eclectic approach is taken to work with this client, with elements of hypnotherapy, EMDR, and trauma-focused cognitive-behavioral therapy incorporated, with the goal of helping Client E tap into the emotional states that she has long been repressing.

Client E has had no problem stabilizing and shows a good ability to intellectually process what happened to her at the time of her sexual abuse, but she acknowledges that she is blocked off from the feeling. Journaling, talking, and using EMDR with traditional visual elements does not seem to help. Then, one session, as Client E and her counselor walk through the experience of the sexual assaults again, Client E remembers that the 1980s song "Tainted Love," performed by Soft Cell, was always playing in the background on the stereo whenever her abuser molested her. Client E is willing to listen to the song during a counseling session, hoping that adding the element of sound will add another level of exposure that might help her tap into the emotions she needs to access in order for resolution to be achieved. As soon as the song is introduced, the client displays a higher level of affective connection with the memories of the abuse, which ultimately helps her to release many of the terror-based feelings that she had been repressing.

Case Study 3

Client F presents for counseling treatment to help her manage mental health symptoms. A woman in her 50s, Client F has been medically treated for mood management concerns over the years, but in talking to a clergy member, she realized that she needed to enter counseling to address the past traumas that she never seems to get over. Client F is certain that if she could resolve these issues, she would be better able to manage her mood.

Client F is treated using trauma-focused cognitive-behavioral therapy. This approach incorporates many of the standard principles of cognitive-behavioral therapy but emphasizes the importance of examining the past or trauma-related etiologies of negative schema. Although she reports immediate relief from the distress and torture she typically experiences when thinking of her past, she seems to have difficulty integrating it into her present ability to deal with her emotions. Her therapist observes that there still seems to be a great incongruence between what she is feeling and what she is articulating. At one point about midway through the treatment sessions, the therapist asks Client F, "What do you think would help you to really connect with these feelings that you are still holding on to?" Client F pauses for a moment and then reports, "Probably the sound of children laughing. That sound has always brought me great comfort but has caused me great emotion at the same time…probably because when I was a kid, I always wished I could laugh, but I couldn't."

At this point, the therapist obtains a sound sample of children laughing online. She encourages Client F to sit comfortably in the office recliner and notice. Client F does this, and upon hearing the laughter, there is an immediate release of emotion. The therapist allows Client F to experience the release, then they continue with their sessions, noticing a greater shift in Client F's ability to express her emotions after this simple, sonically assisted catharsis.

Strategies for Helping a Client Encounter Past Material

Using Music to Access "Stuck" Material

Traumatic memories cause disturbance because they have never been processed, or digested, to an adaptive state of resolution. In essence, they become stuck in the volatile, limbic regions of the brain and will likely remain so unless a therapeutic mechanism is used to process the traumatic material. As noted, different methods can be used to assist in this process, and no one method seems to be a panacea for everyone. Because music is stored in the brain in state-specific forms, it makes sense that music can be used alone or in concert with other therapeutic techniques to elicit emotion and ultimately help a person through his or her unprocessed trauma [2].

Before proceeding with these suggestions, it is important to reiterate that these methods should not be tried unless proper stabilization is in place. Movement from stabilization to the working through of the traumatic material is largely a clinical judgment call; there is no one stage at which this movement should occur. Although perfect stabilization is not realistic for someone with unresolved traumatic material, there should be some reasonable assurance that the client is able to access the coping and stabilization skills covered as part of stage 1 during periods of high distress.

With stabilization in place, one can begin to think critically about how music can be used to help a client process trauma. The most obvious way that this can be accomplished is to directly ask the client if he or she remembers any music or sounds associated with the traumatic memory or memories. Some clients may have similar remembrances to that of Client E—a musical memory associated with a specific traumatic experience. Even if a specific piece of music is not associated, the client may have a clear connection to a specific sound, like the harsh tone of an abuser's laugh, the sound of an explosion, or the steps of an abusive mother.

Reflection

Spend a moment reflecting on the concept of empowerment. What songs or what styles of music most empower you? What songs would you would put on a playlist to access during various times of need?

Even if a client does not associate a piece of music or sound with a traumatic experience, if a solid working alliance is in place, one may consider probing the client about it. For instance, invite a client to be silent for a moment, and as he or she brings up the image or memory of the traumatic experience, ask him or her to notice if there are any sounds in the memory.

Regardless of the primary therapeutic modality used in one's practice to help a client work through traumatic memories, elements of music and sound can be incorporated. The most ideal set-up would be to have access to easily played music through a computer with speakers. This will allow a song or sound to be played during the session as a means of enhancing the therapeutic modality. This choice can be a valuable tool to accessing part of the memory connecting to it emotionally. Playing the right piece of music (or sound sample) connected to the traumatic experience at the right time can be the application of the plunger needed to unclog one's emotional drain.

Although the ideal is to have access to sound samples in the office, this access is not totally necessary for the technique to work. Inviting clients to tune into the sound element of a memory can also work. In other words, bring up the same traumatic memory but invite the client to remember the sounds of the event.

Musical Journaling

Journaling is a method clients often incorporate to help with catharsis. In some cases, people begin journaling on their own; others begin at the direct suggestion of a therapist. Journaling can be useful during stage 2 work, especially because emotional material may arise between office sessions and the journal is an excellent place to record and to work through some of these new discoveries. Clients should be assured that journal writing does not have to be perfect; it is simply a place where one can express some of the thoughts and the feelings that are causing distress.

As with other traditional therapeutic strategies, music and sound can also be incorporated into the journaling process. Songwriting is a logical extension of journaling, but a client does not have to be a songwriter or musically inclined to benefit from musical journaling. Clients may compile a series of songs that reflect what they are experiencing as part of healing from traumatic memories. This exercise can be taken a step further by encouraging the client to put a playlist together and listen to it, then journal in a very free-verse, stream-of-consciousness manner about the feelings that a song or a whole playlist are generating. If a client is more inclined to prayer and meditation, he or she can listen and meditate instead of listening and writing; many options can be explored.

Music-Assisted Focusing and Somatic Psychology

Focusing and somatic methods are two related approaches that are often employed to resolve traumatic memories. Focusing involves paying attention to inward body cues, resulting in increased awareness of how the body reacts in certain situations. The purpose of focusing is not to get in touch with how one feels or thinks in specific situations or when pondering a particular memory; rather, it allows one to access what is going on physically in the body during a specific situation or when faced with a memory. In somatic psychology, a client learns to track, on a body level, his or her sense of experience [13].

A simple way to incorporate principles of focusing and somatic experiencing is to replace the often-used therapy questions of "How does that make you feel?" or "What do you think about that?" with the question, "What is going on in your body right now?" Clients can be invited to notice and share any body sensations. The following is an example of incorporating such a strategy without music.

Client: I don't even have words for it anymore. My mother just makes me so mad! I don't know if I can even talk to her after this last incident.

Therapist: So, even as we're talking about your mother right now, what is happening in your body?

Client: She just makes me want to jump out of my skin. My stomach is in knots, too.

Therapist: Just sit back for a moment and be with those body sensations. Don't judge them. Notice that your mother makes you experience those sensations in your body. (Quiet for several moments.) So, what's happening now?

Whatever the client may report in this flow, continue to ask questions that are connected to the body experience and allow the client to notice it nonjudgmentally. This body-based tactic is one of the simplest ways to bring the body, and thus the whole brain, into the therapeutic process.

Focusing and somatic techniques as forms of processing may not come easily to everyone, especially to those who are blocked off emotionally or, as is the case with many trauma survivors, who are out of touch with their body experiences. To introduce the idea of focusing and listening to the body, music can be added. The process here is similar to the discussion in stage 1 in terms of using music to develop a vocabulary of feelings. In this approach, the client will identify a song that is part of his or her life experience, perhaps one of the songs that the client came up with during a musical journaling exercise.

If a client has difficulty selecting a song that matches his or her experience, the clinician can suggest one. Then, cue the song or sound clip and invite the client to simply pay attention to the body as the song plays. Let the client know that he or she may talk about body sensations during this process or simply stay silent and observe the music. After the song or sound sample has ended, ask the question, "What is going on in your body right now?" If a person is otherwise blocked from expressing body-based experiences, the likelihood is greater that he or she will be able to articulate feelings if music is used to assist.

Using Strategies in Group Settings

For counselors with solid experience facilitating a working group (i.e., one in which most members are actively working on the change process) with safeguards in place to properly close groups in which intense material has been shared, music strategies can be adapted for group implementation in stage 2 work. If the majority of group members seem to be stuck on a particular issue (e.g., maintaining resentments, using dangerous activities to escape pain, repressing emotional experiences), identify a song that, if played for the group, may elicit a cathartic experience in some members. Even if only one group member is obviously affected when the song is played, other group members may relate to and be impacted by the experience. Any sharing brought about by the music is material for clinical discussion within the group.

If a member of the group is using musical journaling as a strategy in between sessions, consider inviting that group member to share some of his or her creations and/or discoveries with the group. Once again, a great deal of meaningful discussion can result from this sharing.

A focusing exercise with music can also be applied in a group setting. As the piece of music is played, encourage listening with nonjudgmental recognition of the body sensations, feelings, experiences, or memories that the music elicits. The operative difference is to facilitate a discussion about the experience with the rest of the group following the initial exercise. The hope is that, in sharing experience and prompting further discussion, members of the group can derive therapeutic benefit.

Assessing Ability/Skill to Use Music in Stage 2

It is likely that many professionals will feel confident about using some music-based strategies in stage 1 work, although incorporating music into the stage 2 process may not be for everyone. While incorporating these strategies into stage 2 may seem easier with a vast knowledge of music, musical competence or talent is not a prerequisite to use music in this stage. However, having a basic appreciation of music and its healing potential is an important component of using music in this stage of the therapy process.

Even more important than music appreciation is being willing and able to handle the intense level of emotion that may be elicited from incorporating music into working through trauma. If a therapist has the self-awareness to help people work through their traumas without getting dysregulated, incorporation of some of these strategies into therapy practice is possible and potentially very beneficial. Some professionals may be more comfortable if they try some of these techniques on their own first. For instance, do a focusing and body-awareness exercise after playing a piece of music that relates to the story of your own life and experience how powerful these strategies can be.

STAGE 3: USING MUSIC IN THE REINTEGRATION (RETURN TO OPTIMAL FUNCTIONING) STAGE

As discussed, reintegration/reconnection with society is the third stage of the consensus model. In this stage, the therapist assists the client to take the gains made during the stabilization and working through of trauma stages and apply them to the improvement of life functioning, social interactions, and personal well-being. Clearly, if a client is seeking outpatient services, then reintegration-type activities and returning to optimal functioning are being done throughout therapy. However, the importance of reintegration as a separate stage following the working through of trauma cannot be overestimated. The goal of work in the reintegration stage is to help a client learn how to maneuver through life without burden and return to the optimal functioning that he or she deserves, and music can help with this process.

Case Studies

Case Study 1

Client G is a high school student of above-average intelligence who has always struggled with standardized testing. Though she likes music, she has never fully appreciated how it could help her cope with test anxiety. Having taken all of the courses she needs to prepare and working with her guidance counselor to address the mental blocks that she needs to overcome, she feels ready to retake the Scholastic Assessment Test (SAT) at the beginning of her senior year. A few days before the test, her friend hands her a CD that he created for her. He explains that he included the song "Eye of the Tiger" and that she should listen to it on a loop before going in to take the test. Not only does Client G find listening to this music energizing, but she also finds the meaning behind the song and the CD touching. The fact that her friend thought of her enough to send his motivation with her gives her an extra boost of confidence that helps her to perform as best as she can on the exam.

Case Study 2

Client H is a firefighter and emergency medical technician in a small town who has struggled with symptoms of PTSD for more than seven years. A perceived lack of understanding and compassion in his department is exacerbating his PTSD symptoms, and he finds going to work and dealing with others to be the most miserable part of his job, in some ways a more difficult task than fighting fires and rescuing people. Although Client H is not a musician, he enjoys music and is happy his therapist is willing to entertain his discussions about songs, no matter how dark they are. Client H completes a full course of stabilization (stage 1) and working through of the trauma (stage 2) using EMDR and some trauma-focused cognitive-behavioral therapy strategies. However, Client H's main concern continues to be returning to work now that he is feeling better. Together, Client H and his therapist develop a coping plan in order to deal with the drama in his work setting. Part of this plan includes listening to "angry" music in the car on the way to work. For Client H, getting his angst out by singing along with hardcore heavy metal music in the car on the way to work helps him to release his anticipatory anxiety about interacting with his fellow employees. Although Client H uses gentler techniques (e.g., breathing, grounding) while at the fire station, he finds that having the musical outlet in his car makes a difference for him in being able to return to work.

Case Study 3

Client I is a man, 58 years of age, who presents for PTSD treatment following a major robbery at his place of work. During the robbery, Client I was shot and barely escaped with his life. Client I initially struggled during his treatment, but he eventually experienced a great reduction in PTSD symptoms using a combination of pharmacotherapy (prescribed by a staff psychiatrist), trauma-focused cognitive-behavioral therapy, art therapy, and some somatic experiencing. Although Client I does not seem to connect with traditional EMDR therapy when his therapist attempts it, there is one element that he does like—the sound tones. (In EMDR, eye movements do not have to be used to generate the bilateral stimulation that defines the EMDR approach to psychotherapy. Alternating tapping/tactile sensations or beeps [typically generated by a specialized machine that can provide the alternation] are acceptable alternatives.) Client I indicates that simply putting the headphones on and focusing only on the beeps proves to be extremely relaxing. The therapist observes that drawing seems to help him with processing the trauma and listening to the tones serves as a form of soothing self-hypnosis.

As an experiment, Client I is sent home one day with a CD of just the beeping sounds on a loop to determine if it will have an effect even without the alternating capacity generated by the EMDR machine. At his next appointment, Client I reports that when he needed to relax, he simply put on his "beeping" CD and he was able to relax. He also noted a decrease in heart rate during listening sessions.

Upon termination of treatment, Client I indicates that using his "beeping" CD has become a regular part of his life whenever he feels panic or anxiety. Although Client I has done work in therapy to address the traumatic material, he continues to live in a dangerous neighborhood near the place of his shooting, so triggers are unavoidable. Client I indicates that the "beeps" are something he will call upon whenever he needs to relax and self-soothe.

Strategies for Reintegration

If one is able to incorporate some of the strategies from stages 1 and 2 into practice with clients, the same logic can be carried into stage 3 work. If stage 3 is the period during which the client is returning to optimal functioning, certain needs must be met for this to happen. Perhaps the client will identify a need to feel a greater sense of empowerment overall or a continual need to calm him or herself in certain situations. Whatever the need, a musical strategy may be applied.

Applying Skills from Earlier Stages with Redirected Purpose

The playlist strategies identified for stage 1 work can be applied to stage 3 as well, depending on client need. The client may want to move songs around on the playlists, deleting some and adding others, depending on how their experiences have changed as the result of therapy. The meditation-like strategy of using music to replace guided imagery can also be applied in stage 3. If a client must face a difficult situation, using a piece of music that has been identified as a positive resource can be a big help.

Even some of the skills from stage 2 can be applied as stage 3 reintegration strategies, especially those that involve songwriting or listening to a piece of music to help a client connect with his or her feelings and body experiences. Clients who are having trouble listening to their body or to their intuition can listen to a piece of music and spend time noticing body-level reactions; this is a strategy that can be used throughout life.

Using Music to Define/Embrace Empowerment

Empowerment is a term often used in the therapeutic literature, and therapists are charged to empower clients, with the ultimate goal of clients being able to tap into their own senses of power. As one official definition reads, empowerment "provides a client with a sense of achievement and realization of his or her own abilities and ambitions" [15].

The right song can certainly help clients tap into personal empowerment. Songs that allow clients to feel better about themselves and their place in the world can be an important part of reintegration. If a client is open and willing to define songs that can help with the empowerment process, this is a benefit to the therapeutic process.

INCORPORATING MUSIC INTO TELEHEALTH SERVICES

During the COVID-19 pandemic and continuing after, there has been an increased interest in and utilization of telehealth mental health services. Some populations, including active-duty military service members and those living in remote or underserved areas, rely almost exclusively on access to mental health care via distance counseling and therapy. Music can be easily and effectively adapted to be incorporated into these types of services. Research indicates that including music in tele-therapy yields positive participant responses, including decreases in pain, anxiety, and depression [26]. Clients who rely on telehealth services should not be excluded from these types of interventions; distance delivery of music through digital platforms can be a part of all phases of trauma processing and ensuring continuity of care [26].

4. CONCLUSION

For those who have chosen to access and harness it, the healing potential of music cannot be paralleled. As discussed in this course, music is a vital part of the human experience in every global culture, and because there are so many different varieties of music, it has great power to reflect and honor the subjectivity of the human experience. Thus, one can argue that if music is not used as part of the therapeutic process, we are missing an opportunity to truly understand a client and work with a medium that honors one's individuality.

This course has reviewed some foundational material about music, specifically looking at definitions and interpretations within historical and cultural contexts. Fundamental knowledge about how music works at the brain level and the role that music can play in promoting harmony among the various functions of the human brain were explored. The three-stage consensus model of trauma treatment was presented as a paradigm of treatment, through which approaches to music-based interventions were presented.

One does not need to be a musician or even conversant in music to be able to incorporate musical interventions into clinical practice. All it takes is common sense and an awareness of how music has impacted your life, your memory, and even your own healing.

5. RESOURCES

BOOKS

Oxford University Press' Global Music Series: Wade BC. Thinking Musically: Experiencing Music, Expressing Culture. New York, NY: Oxford University Press; 2012.

Dorrell P. What is Music? Solving a Scientific Mystery. Auckland: Philip Dorrell; 2005.

Levitin D. This is Your Brain on Music: The Science of a Human Obsession. New York, NY: Plume/Penguin; 2007.

WEBSITES

American Music Therapy Association

https://www.musictherapy.org

Association for Creativity in Counseling

https://www.creativecounselor.org

European Society for the Cognitive Sciences of Music

https://www.escomsociety.org

International Association of Expressive Arts Therapy

https://www.ieata.org

Works Cited

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