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.

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.

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 While this model's use in terms of neuroanatomic evolution is considered by some to be outdated or oversimplified, it is useful as a purely explanatory tool.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:

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].

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.

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:

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.

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.

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.

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.

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.

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.

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.

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:

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)?"

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.

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.

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.

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.

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].

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.

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.

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.

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.

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.

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].