I read with great interest the clinical paper by Jaap Orth in the July 1, 2005 edition of Voices (Volume 5, number 2, Article #182) titled, Music Therapy with Traumatized Refugees in a Clinical Setting". Refugees and evacuees are on everyone's mind in the United States these recent days following Hurricanes Katrina and Rita in the late summer of 2005. I am very interested in the use of music therapy to treat posttraumatic stress disorder, whether or not the stressor is a natural disaster.
Mr. Orth has devoted more than 20 years to the treatment of traumatized refugees at Phoenix, a specialized unit in Wolfheze, The Netherlands. He notes that scholarly accounts of music therapy methodologies are lacking in the treatment of refugees and asylum seekers, and toward this end he presents this paper.
I am a student in music therapy at the University of Louisville currently assigned to a practicum at an acute inpatient psychiatric hospital. Music therapy occurs in groups at this hospital, and I was interested in Mr. Orth's observation that a group is too intense for his refugee clients. He prefers to work individually with his clients at Phoenix because he feels that he can provide more safety, a less intense setting, and accommodation for cultural differences. How wonderful to have the financial support to provide individual care for his clients!
I was struck by the similarity in the music therapy goals at Phoenix and at my practicum site. Mr. Orth cites the following goals for his refugee clients:
To strengthen self-determination, enable the clients to manage their own affairs, and express themselves in a socially acceptable manner. His treatment strategies include: compose original music, learn an instrument, make musical products such as cassette recording, and improvise. At our facility, music therapists pursue similar goals using similar musical resources. I suppose that should come as no surprise since both are mental health settings. It reassures me as a student to see congruity in music therapy theory and practice around the world.
Lately, I have been following attempts on the music therapy list-serve and the American Music Therapy Association website to organize therapy for victims of recent hurricanes. It is heart-warming to know that our profession is involved in the crucial events of the day in the U.S. as well as in the Netherlands.
I have great admiration for what Jaap Orth has been able to accomplish in his work in The Netherlands. Traumatized refugees are among the most vulnerable clients presenting to music therapy. Mr. Orth is a credit to our profession. May we all learn from his experiences.
In his article, Music Therapy With Traumatized Refugees in a Clinical Setting, Jaap Orth illuminates many important techniques a music therapist may employ when working with PTSD sufferers. I found the article intriguing because of my personal interest in this population. Mr. Orth does a fine job of conveying the unfortunate truth that trauma is not culturally selective. The intrusive thoughts, avoidant states, and hyperarousal that devastate a refugee from Somalia, also wreac havoc on the Cambodian survivor. However, he demonstrates that through music, and more specifically, through culturally appropriate music, the shattered psyches of the aforementioned examples may be repaired. The author lays out in clear terms how music therapy has been shown to be an important means by and through which PTSD sufferers may re-develop healthy psychic functioning. Thus the ego is strengthened, and clients have a foundation on which to discover their true potential. Orth's focus on individual treatment seems the most effective means by which a PTSD sufferer may process his or her past trauma, and the problems created by it.Psychological trauma is so insidious in that it stunts both healthy emotional growth, and the ability for clients to rely on their own intuition and judgments. Their capacity to depend on the soundness of their own decision-making and perception of reality is often non-existent, or severely flawed at best. By identifying the trauma, and the dysfunction associated with it, clients begin to realize inner potential, and growth occurs.Wheeler (1983) explains how insight music therapy can help clients discover more about themselves, and in turn, their inner motivations: “The major focus of this music therapy is on feelings, the exposition and discussion of which lead to insight, which in turn results in improved functioning” (Wheeler, 1983, p.10). . Music can tap into those elements by creating a conducive environment in which they can be expressed.
Mr. Orth correctly points out that interpretation and perception of music, being so subjective, can easily be lost in cultural translation.One must be sensitive and open minded in applying music in a therapeutic context. Davis, Gfeller & Thaut (1999) stated:
Wigram, Saperston, & West, 1999, point out the traditional use of pre-recorded music: “Most previous studies have utilized musical selections in a traditional manner by presenting pieces as they were originally composed to meet the artistic and aesthetic needs of the performers and listeners” ( p.60). Mr. Orth asserts that pre-recorded music should actually be chosen for its ability to fit an individual client’s particular needs. He proposed a way of using music that may have a more positive impact on physiological responses (which are at the core of PTSD).The power of music has, in fact, the potential for exacerbating the trauma. Consider a therapist using a Wagner symphony with a Holocaust survivor, or a song that an abused child was traumatized to. The correct musical choice may oftentimes reveal itself only after some time has been spent getting to know a particular client. Assessment of those who have witnessed war, famine, genocide and other atrocities must be geared toward their unique history.
Within the realm of psychological trauma, findings from good, sound research cannot come quick enough. Silverman (2007) reported, “Continued research evaluating treatment is imperative if music therapy is to continue to survive in psychiatric care” (Silverman, 2007, p.24). However, in the meantime, music therapy is changing the lives of a vast majority of PTSD victims who choose it as their therapeutic tool. According to Davis, Gfeller, & Thaut (1999), “Music therapy is frequently used to eliminate or reduce the impact of maladaptive behaviors. Because music is a art form that appeals to many people, it has great potential as a treatment tool with widely divergent therapeutic needs” (Davis, Gfeller, & Thaut, 1999, pp. 115-6). The aim of the music therapist who is treating a client with PTSD is to re-integrate the fragmented elements of self that he or she has lost. As the client re-develops, or develops for the first time, a sense of belonging to the group or community to which he or she bound, a sense of belonging to oneself will begin to take root. In addition, the client is in a better position to learn healthy coping skills. To live with people is to live with trauma, and until we can be sure there will be no more child abuse, no more Holocausts, no more wars, we can be sure there will be psychological trauma. I wholeheartedly agree with Mr. Orth that music must be carefully chosen on an individual basis tin order to best help a client. To best achieve this, research must continue to provide the music therapy community with useful data, as well as a continually growing list of culturally specific musical choices, and the cultural significance of that music. Wigram, Saperston, and West point out that a standardization of musical stimuli would eliminate confounding variables (1999). This is inherently problematic, given the subjective essence of music. Furthermore, as Orth points out, interpretation and perception of music can vary widely.However, a standardization could be a starting point for music therapists to find footing when they are required to choose specific music for a specific client. Music needed for relaxation, for example, could be categologued by country in a particular database. A music therapist need only to go to the type of music needed, and find the country or culture of the client(s) he or she is working with. Sub-categories, such as folk music, politica music, popular music-all specific to that country/culture, would also be available. This could be an expedient means by which music therapists could access specific music for a specific clientelle. Music therapists could also spend time learning the music of different cultures, and the many subtle nuances inherent in it. This World Music Therapy Library would prove to be an invaluable tool for music therapists who desire to be as helpful and effective as they can be.
References
Davis, W.B., Gfeller, K.E., & Thaut, M.H. (1999). An introduction to music therapy: Theory and practice (2nd ed.) Boston: McGraw-Hill.
Silverman, M. J. (2007). Evaluating current trends in psychiatric music therapy: A descriptive analysis. Journal of Music Therapy, 44 (4), 388. Retrieved December 10, 2008, from ProQuest Psychology Journals
Wheeler, B. L. (1983). A psychotherapeutic classification of music therapy practices: A continuum of procedures. Music Therapy Perspectives, 1 (2), 8-12.
Wigram, T., Saperston, B., & West, R. (1994). The art and science of music therapy: A handbook. Routledge. Retrieved December 8, 2008, from http://www.google.com/books
Response to "Music Therapy with Traumatized Refugees in a Clinical Setting"
Around the time I was reading Voices articles I had also had a conversation with a friend of mine who was displaced from his home in New Orleans, Louisiana by Hurricane Katrina in 2005. Over three years after this traumatic experience he still struggles to make a steady living, causing a level of stress he may not have otherwise known. Although it is not the same as the post-war, culturally focused picture of post-traumatic stress disorder (PTSD) emphasized by Jaap Orth in the article "Music Therapy with Traumatized Refugees in a Clinical Setting," this connection is certainly what first caught my interest.
When reading the article, one learns of four particular approaches to music therapy Orth has used in his work with traumatized refugees at the Phoenix Centre in the Netherlands. These four methods extensively used by Orth are composing one’s own relaxation music, learning how to play an instrument and playing together with others, making one’s own musical product, and improvisation. These are also popular methods that can be used with a variety of populations, but he makes a beautiful case for their use with traumatized refugees specifically by focusing on the flexibility they provide in being able to cross cultural boundaries. He also provides examples of clients who have benefited from them.
While I do not question the effectiveness of these methods, I am left to wonder whether Orth is merely making "a contribution to the development of a methodology in music therapy with traumatized refugees," as he says in his introduction, or whether he is subtly suggesting that one should use these methods over others like vocal holding or guided imagery and music (GIM), which he also discusses. All music therapy methods have both advantages and disadvantages, yet the only disadvantages mentioned are those related to GIM. Would Orth’s methods not also have their own disadvantages?
Please do not misunderstand, however. I do not feel as though Orth is hiding anything. He has obviously made wonderful contributions to the development of music therapy methods for traumatized refugees. Rather, I feel as though he is downplaying his own achievements by not making bolder comparisons between his methods and others. Orth obviously saw a need to develop methods for working with this population and spent 20 years doing so, yet in this article seems to lack the conviction to say that his methods are better than those from which the need for newer methods first stemmed.
As a music therapy student, I have been taught to be discriminating and to ask questions rather than blindly accepting and relying on the opinions of others in the field. I wanted very much to be able to accept Orth’s methods as preferred treatment, but after reading this article I cannot say that I would be any more likely to use them than others. Although I have questioned this aspect of Orth’s discussion, I maintain a respect for him as I would other professionals in the field. It is perhaps heightened by his concluding statement of "hope that the above article will give an impetus to further development of methodology, based on experience and (empirical) research," because despite 20 years of work it would still be naïve and crippling to the profession to think that further progress is impossible.