Treatment description and case series report of a phased music therapy group to support Veteran reintegration

ABSTRACT

Music therapy is becoming increasingly prevalent in rehabilitation programs serving military and Veteran populations in the United States. Music therapy is integrated into interdisciplinary models and positioned to treat brain injury, post-traumatic stress disorder, and other psychological health conditions at military installations and Veteran medical centers nationwide. Phased group music therapy is delivered in a longitudinal treatment model to assist in the rehabilitation of service members and Veterans. Different phases of group music therapy are aligned with a treatment trajectory that exists on a clinic to community continuum to support recovery and reintegration. This article provides a description and case presentations of clinical programming. Information was accessed from patients’ electronic medical records, clinical documentation, therapist observation, and patient interviews. Interviews were transcribed and a content analysis was conducted by the authors. Emergent themes from the patient interviews included social relationships, community reintegration and transition, and post-military occupational success. Patients reported that group music therapy provided skill-building opportunities that were helpful for them during military service transitions, specifically active duty to Veteran status. Support skills included rapport-building and enhanced camaraderie. Furthermore, music therapy appeared to bolster peer connections through shared experiences, which decreased isolation, increased socialization, and supported reintegration.

KEYWORDS:

• Music therapy
• military
• Veterans
• reintegration

What is the public significance of this article?—This article proposes that phased group music therapy treatment can support active-duty service members and Veterans experiencing traumatic brain injury and associated psychological conditions within their rehabilitation process, familial relationships, positive peer connections, transition support, occupational success, and community reintegration.

Introduction and literature review

Music therapy (MT) is an evidence-based practice that addresses the physical, emotional, cognitive, and social needs of individuals and groups. Treatment is aimed at supporting clinical goals in a therapeutic relationship through the implementation of evidence-based music interventions facilitated by a credentialed professional who has completed an approved MT training program (American Music Therapy Association & Certification Board for Music Therapists, 2015). The use of music in the United States (US) military healthcare system dates back to WWI and WWII when music listening experiences were recommended for returning Veterans convalescing in Veteran hospitals (American Music Therapy Association [AMTA], 2014). In a technical bulletin published by the War Department in 1945, a document titled Music in Reconditioning in ASF Convalescent and General Hospitals outlined a music program for rehabilitating injured service members (Rorke, 1996; U.S. War Department, 1945). Currently, MT is becoming increasingly established as a viable treatment option in military and Veteran healthcare systems. This is being supported through an initiative of the National Endowment for the Arts (NEA), Creative Forces®: NEA Military Healing Arts Network.

Creative Forces®: NEA Military Healing Arts Network is an initiative of the National Endowment for the Arts in partnership with the US Departments of Defense and Veterans Affairs. Creative Forces is managed in partnership with Americans for the Arts and the Henry M. Jackson Foundation for the Advancement of Military Medicine. Creative Forces supports the integration of creative arts therapies (e.g., art therapy, dance/movement therapy, music therapy) as a standard of care in interdisciplinary treatment models for rehabilitation of traumatic brain injury (TBI), posttraumatic stress disorder (PTSD) and other psychological health concerns at military and Veteran health clinics nationwide including a telehealth component (Bronson, Vaudreuil, & Bradt, 2018; Vaudreuil et al., 2020a). Creative Forces operates using three pillars: clinical, community, and capacity, all which promote clinical treatment and reintegration through community arts engagement with a strong emphasis on research across this continuum (Betts, 2020).

Socialization and transition support are essential for service members recovering from traumatic brain injury (TBI), post-traumatic stress disorder (PTSD), and associated symptomatology such as anxiety, depression, fear, and survivor guilt (Bronson et al., 2018). Ahern et al. (2015) interviewed service members and found peer support to be the most beneficial condition for successful military transitions. They also found that service members faced challenges with peer connection and that shared experiences created stronger support systems while adjusting to civilian life. Peer support serves as a preventative measure to address the biopsychosocial effects of trauma such as isolation, moral injury, substance use, and sleep disturbances, which are primary co-morbidities commonly experienced by military-connected populations (Rutherford & Allegria, 2010). This includes service members who are transitioning to Veteran status. Veterans of the Global War on Terrorism show increased risk of long-term issues such as homelessness and premature mortality further warranting the need for transition support (Wands, 2013). Implementing group-based MT treatment can provide priming for service members who are approaching the end of their military careers by creating structured and social environments that help them connect to Veterans in their communities (Vaudreuil, Bronson, & Bradt, 2019).

Group MT encourages opportunities for creativity and self-expression among participants, strengthening a sense of “we-ness” (Brown, 2000). Studies support that the creative process utilized in group MT may increase interpersonal communication, peer support, and sense of belonging in patients with PTSD (Blake & Bishop, 1994; Burt, 1995; Dixon, 2002; Koenig, Maguen, Monroy, Mayott, & Seal, 2014; Pothoulaki, MacDonald, & Flowers, 2012) For example, results from a group drumming intervention with soldiers found that participants reported increased feelings of unity, togetherness, belonging, connectedness, and openness (Bensimon, Amir, & Wolf, 2008). MT has shown efficacy in resilience-building by raising awareness of personal struggles, providing opportunities for participants to step outside of their comfort zones through structured risk-taking, and allowing clients to take pride in their creativity (Baker, 2013; Vaudreuil et al., 2019). Furthermore, MT groups can support camaraderie, which is reflective of military training and culture. For example, service members who participated in one MT group session reported benefits of making music together as a team (Vaudreuil, Biondo, & Bradt, 2020b).

Intensive treatment approaches have been shown to be effective in the recovery of TBI and PTSD (Bronson et al., 2018; Cicerone, Mott, Azulay, & Friel, 2004; Defense and Veterans Brain Injury Center [DVBIC], 2017). Therefore, the phased MT group treatment approach presented in this article was developed for patients receiving longitudinal rehabilitation using evidence-based MT interventions within an intensive care model.

Method

The TBI Clinic at Joint-Base Elmendorf Richardson (JBER) in Anchorage, AK is an outpatient clinic that provides longitudinal treatment to active-duty service members and Veterans of the US Air Force, Army, Alaska Air National Guard, and their families. The Creative Forces MT program at JBER addresses the needs of patients with mild TBI/concussion, PTSD, and psychological health symptoms in a patient-centered, interdisciplinary program.

Program description

This paper features a clinical treatment description and case report series of three patients who engaged in the phased MT group treatment during their transition from active duty to Veteran status. Patients were referred by a nurse practitioner to address symptoms related to TBI and PTSD. The program description follows a three-phase approach to care: (1) 6-week MT group series; (2) active music making/jam group; and (3) community engagement through musical performance. Case examples are based on service member interviews and focus on how this phased group MT approach supported reintegration. All service members were interviewed about their experiences and a content analysis conducted by the authors highlighted four areas: 1) symptom management, 2) social connections, 3) military transition, and 4) emotional support. Pseudonyms are used to maintain patient confidentiality.

Treatment Phase 1: 6-week MT group series

The 6-week MT group series consists of four components, which introduce new music experiences built on information from previous sessions. This sequence creates opportunities for patients to engage in collective skill-building and teamwork by applying newly acquired information in real-time. The group format allows for the development of social connectedness (Brown, 2000) between patients in a structured environment, which can then be generalized to community settings using the familiarity of group dynamics to support reintegration (Vaudreuil et al., 2019). The 6-week MT group series consists of six sessions that meet once weekly for 60 minutes.

Component 1: Check-in/music-based relaxation

Component 1 includes a check-in that promotes discussion about patients’ musical interests, use of music in everyday life, and preferred musical genres. A brief music-based relaxation is facilitated after check-in to promote physiological and emotional regulation before initiating expressive engagement (Pelletier, 2004).

Component 2: Introduction of musical material

Component 2 includes a combination of information review and new material introduced through familiar songs. Using music to contextualize information allows for facilitation techniques that emphasize verbal cuing and demonstration. Furthermore, the music therapist is able to assess patients’ cognitive abilities (Thaut & Hoemberg, 2014).

Component 3: Music making, lyric analysis, and songwriting

Component 3 introduces active music making, lyric analysis, and songwriting in succession. Instrument playing and information transfer to multiple instruments during active music making requires cognitive and creative flexibility (Thaut & Hoemberg, 2014). When this process becomes frustrating, patients are recommended to utilize the relaxation techniques from group check-in.

Lyric analysis and songwriting are presented in weeks 4 through 6 to facilitate insight of self and others, emotion identification, creative expression, and communication. Lyric analysis supports a deeper level of understanding and songwriting techniques provide additional connection by integrating personalized thoughts and feelings into the song (Bradt, Biondo, & Vaudreuil, 2019; Silverman, 2019). To initiate meaningful group discussion, the music therapist may prompt the patients to view their life circumstances and goals introspectively as inspired by musical themes, lyrics, and distinct parts of the song with which they resonate.

Component 4: Check-out/processing

Component 4 consists of check-out and group processing during which the music therapist promotes the functional application of music outside of the clinical environment. Upon completion of Phase 1, patients should have the foundational understanding and skills that enable them to engage in self-directed music playing. This outcome is supported by patients’ report that they coordinate collective music making outside of the clinical space.

Treatment Phase 2: Active music making/jam group

Active music making/jam group engages patients in team building, verbal and nonverbal communication, and executive functioning through various music experiences (Bradt, Magee, Dileo, Wheeler, & McGilloway, 2010; Thaut & Hoemberg, 2014). This builds generalizable skills that patients may find useful in other musical and non-musical settings (e.g., performance, occupational, social, and familial). Furthermore, active music making/jam groups provide a supportive environment wherein patients can manage emotions, engage in positive socialization, and seek respite from life stressors through group singing and playing (Bronson et al., 2018). Active music making/jam group occurs once weekly for 60 minutes. Patients attend as often as needed for ongoing support while transitioning from active duty to Veteran status.

Treatment Phase 3: Community engagement

MT promotes reintegration through community performances at venues on and off the military base. These are live, musical experiences aimed at assisting patients’ transformation across varying levels of treatment, providing familial and social validation, and allowing for self-expression and community connectedness (Vaudreuil et al., 2019). By taking an active role in planning performances, patients may experience autonomy and increased agency. This supports movement across a clinic to community continuum from a patient role in MT treatment to a participant in community music engagement. To assure consistency of care, continued MT services are available to patients who require ongoing support.

Case presentations

The following case presentations highlight three patients with TBI and PTSD who successfully completed phased MT group treatment during their transition from active duty to Veteran status. Patients were interviewed about their overall treatment experiences including goal attainment, social engagement, peer support, and community reintegration. Written informed consent was obtained for participation in this study and names have been changed for patient confidentiality.

Case presentation 1

Patient history

“Mark” was a 35 year old Sergeant First Class in the US Army. He served 16 years and three combat deployments. Mark received MT to address feelings of depression, anxiety, and isolation.

Finding happiness again

Mark reflected on his participation in the 6-week MT group series stating, “I remember my wife would say I was always happier after I was done with a music therapy group.” Active music making provided a healthy mechanism to process his emotional pain as he would, “channel his feelings into playing.” During Mark’s completion of the final phase of treatment, he explained that community performance allowed him, “to move forward emotionally by giving back to others through music.” He began to reengage in activities that brought him happiness in the past. He stated, “Music therapy helped rekindle interest in things I used to love to do like fishing, sports, and archery.”

Stepping outside of “the comfort zone” & reintegration support

Mark’s engagement in MT provided him the opportunity to try something new in a supportive environment. He shared, “I was scared in the beginning then realized [playing music] wasn’t as intimidating as I had thought it would be. I began applying that theory to life … Try[ing] new things and push[ing] myself out of my comfort zone.” Mark used the skills that he developed in MT to reintegrate as a Veteran, specifically when he was applying for jobs. He shared, “I was dreading working in the civilian sector and music therapy helped me take a step forward and apply for a job. Before the interview, I gave myself a pep talk- just like I did in group music therapy. It helped me not to be scared to try new things.” Mark got the job and still plays the ukulele.

Case presentation 2

Patient history

“Sam” was a 52 year old Staff Sergeant who served in the US Air Force for 14 years. MT supported Sam’s emotional expression, social support, coping strategies for anxiety, and self-awareness.

Finding a way to express

Sam’s involvement in MT created opportunities that promoted self-expression and self-discovery. He described, “During music therapy I felt like something woke up in me that was gone. I found something in me that I had lost.” By playing his original songs during community performances, he gained perspectives about how his music created connections with other Veterans. He shared, “When I played one of my songs at a local Veteran’s hospital, a patient there began to cry as he connected to my song. It was humbling and rewarding for me that I made an emotional impact on his life.” Sam shared how his music provided insight for his wife, “When I shared my song with her, she said, ‘This was so good and now I better understand what you went through.’ I could tell her in my songwriting what I wasn’t able to tell her in words alone.”

Anxiety with military transitions

MT helped Sam to focus on something other than transitioning out of the military. He stated, “It helped me forget how sad I was feeling [about ending military service]. I would get caught up in the music and always felt good while I was playing.” Sam provided other group members experiencing similar feelings with peer support. He explained, “It felt nice to help other guys who were starting their transition process. Music helped during mine.” Sam continues using music to manage his anxiety.

Case presentation 3

Patient history

“Ryan” was a 31 year old Staff Sergeant in the US Army. He served for 12 years and four combat deployments. He engaged in MT to address self-expression, acceptance, coping, and positive connections with others.

Finding self -acceptance and coping

MT provided Ryan a space for self-expression. He described, “I started writing my own music and it opened my heart and mind, my true feelings would come through. I picked up the guitar more and played because I wanted to, not because I had to.” Instrument playing and songwriting were positive distractions from the anxieties that Ryan associated with military transitions. He explained, “When I picked up the guitar, wrote music, and sang it took all the stress and pain away.”

Creating connections

Ryan reported that group MT helped him establish positive social connections. He shared, “It gave me the chance to hear other people’s stories, and differing levels of trauma. I wasn’t alone and I was understood by other group members. We built a brotherhood.” Ryan attributed MT to strengthening his personal relationships, “I have a deeper connection with my wife who also sings, she sees how music impacts my life and it inspires her.” Ryan summarized his experience in MT, “Music therapy is one of the best things that has happened in my life. It can change your life and is the key to the soul. I used to have so many walls up and was guarded. Bringing music into my life has changed the atmosphere.”

Discussion

Veterans struggle with reintegration due to social isolation, mental health issues, transition to civilian life, and loss of military identity (Blake & Bishop, 1994; Burt, 1995; Dixon, 2002; Koenig et al., 2014). This aligns with the themes identified in the current case presentations regarding phased MT group treatment for Veteran reintegration. Main themes that emerged were symptom management, social connections, military transition, and emotional support. Ahern et al. (2015) indicated that socialization and peer support were predictors of success for military personnel transitioning to civilian life, and their abilities to continue thriving as Veterans. Group MT has shown to provide opportunities for teamwork and shared musical experiences that transfer outside the clinical environment (Vaudreuil, Walker, Freeman, Hogue, & Betts, 2020c). The case presentations demonstrated that patients reported continued music making, engagement in healthy non-musical activities, and development of lasting peer connections.

Additional themes highlight the intersectionality of experiences reported by the patients including benefits for themselves and their loved ones. MT treatment “can simultaneously address and uniquely treat functionality and emotional health by attending to interactions of symptomatology that accompany co-morbid diagnosis” (Bronson et al., 2018, p. 197). Public performances can be validating for patients, allowing for increased expression of their inner selves while feeling connected to audiences (Baker, 2013; Soshensky, 2011). Furthermore, performance in MT can increase community understanding of Veterans (Vaudreuil et al., 2019); this article aligns with existing literature that promotes successful reintegration.

Limitations

Limitations for this study include the presentation of exploratory qualitative data collected from one site. The treatment was facilitated by one music therapist and a small patient sample (n = 3) was interviewed. Additionally, using a non-experimental/observational cross-sectional research design, such as case presentations, findings are not generalizable (Nissen & Wynn, 2014).

Conclusion

MT may provide opportunities for successful transition from active duty to Veteran status. As evidenced by patient reports, this article supports the use of phased MT group treatment to build meaningful relationships and peer support networks. Patients in the phased MT group connected with other group members and their communities through shared music experiences that promoted functional rehabilitation, psychosocial and emotional support, and reintegration. This paper contributes to the growing evidence base of music therapy within military healthcare. Future research is needed to further examine the depth and breadth of music therapy’s benefits across military populations.

Disclaimer

The opinions contained herein represent the private views of the authors and are not to be construed as official or as reflecting the views, opinions, or policies of the Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., the Department of Defense, the National Endowment for the Arts, or the US Government. This document was created free of branding or market affiliations. The authors are operating solely as contributors.

Ethics statement

The case studies presented in this article were determined exempt by the Joint Base Elmendorf-Richardson institutional review committee. Written informed consent was obtained from the participants for the publication of these case reports. This study was carried out in accordance with the recommendations of the Joint Base Elmendorf-Richardson Public Affairs Office and designated as exempt from ethics committee review. All subjects gave written informed consent in accordance with the Declaration of Helsinki.

Acknowledgments

The authors would like to give thanks to the Veterans who contributed to this article by sharing their stories and their family members who supported them during treatment. Additional gratitude is extended to all service members and Veterans who courageously protect our freedom. The authors of this paper would like to acknowledge the contributions of Creative Forces®: NEA Military Healing Arts Network, an initiative of the National Endowment for the Arts (NEA) in partnership with the United States Departments of Defense and Veterans Affairs, for their extensive support of creative arts therapies clinical programming and research. Creative Forces is managed in partnership with Americans for the Arts and the Henry M. Jackson Foundation for the Advancement of Military Medicine.

Disclosure statement

The authors have no declaration of interest. The views expressed in the article are those of the authors and do not reflect the official policy of the Department of the Army/Navy/Air Force, Department of Defense, the Veterans Health Administration, or US Government.

Data availability statement

Data sharing is not applicable to this article as no new data were created or analysed in this study.

Additional information

Funding

This work was supported by the National Endowment for the Arts, Creative Forces®: NEA Military Healing Arts Network.