Time in Between

Molloy College, a private liberal arts college in New York, founded by the Dominican sisters of Amityville, partnered with PRN (Physicians, Residents, Nurses) Relief International and the Dominican Sisters in Jamaica to organize a twice-annual service trip providing primary care, speech-language pathology, psychiatric-mental health care, and medical/surgical teams in rural and urban Jamaica. During the week-long trips, medical staff and speech pathologists move in teams from clinic to clinic, while mental health professionals, along with midwives and psychiatric nurses, work exclusively with the residents and staff at Homestead Place of Safety in Stony Hill, St. Andrew in the northern outskirts of Kingston, Jamaica. The state-operated facility, established as a home away from home, houses girls between the ages of 12 and 18 who experienced neglect or abuse, victimization, and sexual assault, or those in conflict with the law. Music Therapy services were included as part of the mental health team for the first time in October 2016 and provided an outlet for self-expression, an opportunity to foster resilience, a strengthened sense of community, and a supportive response to trauma. In past years, the mental health team found that the girls engaged freely in creative outlets such as art [therapy], and that music was an integral part of their culture and daily routine. Music therapy was therefore recommended to help normalize the therapeutic process, increase engagement, and develop thera-


Intr Introduction oduction
The faculty and administration of Molloy College have recognized the value of Short-Term International Health Missions (STIHMs), which allow for graduate students to immerse themselves in another culture while accruing supervised clinical training in their field. STIHMs support the college's Dominican tradition of community, service, spirituality, and study. Through immersion, STIHMs increase students' cultural aware-ness and awareness of social determinants of health in other countries (Whelan et al., 2018). Members of PRN Relief International-Physicians, Residents, and Nurses-work closely with communities worldwide that lack access to comprehensive services. They deliver clinical care, education, and health promotion, with the goal of returning on a scheduled basis to develop ongoing relationships and administer follow-up care. PRN members typically respond to global emergencies by sending teams to assist in the health care needs of communities affected by disasters. Partnering with Molloy College's Departments of Nursing, Speech Pathology, Clinical Mental Health Counseling and Music Therapy, along with Yale-New Haven Hospital's division of Psychiatry, PRN also provides medical and psychosocial care to communities affected by poverty and trauma.
In October 2016, music therapy services were provided for the first time as part of the mental health team at Homestead Place of Safety in Kingston, Jamaica, as an outlet for self-expression, an opportunity to foster a sense of community, and to support client response to trauma. I was honored to be the first music therapist on the team, along with one of our graduate music therapy students. Since that time, music therapy faculty/graduate student pairs from Molloy College have been an integral part of the interdisciplinary treatment team on an annual basis. Sessions incorporate group drumming and other improvisation, group singing and songwriting, active music listening and song discussion in addition to music mediated mindfulness, art, and journaling. Music therapy group sessions were scheduled twice each day during the five days at Homestead; we also cotreated in groups with the art therapist and social worker at least once each day in planned program time and had spontaneous sessions with individuals or small groups during occasional down time. We were able to share with them something sacred and deeply meaningful, while also light-hearted and fun.
"Homestead's mission is to create a stable, supportive and nurturing environment for girls who have experienced trauma in their lives by providing intervention and rehabilitation" (Orphaned Starfish, 2016). The state-operated facility, established as a home away from home, houses girls between the ages of 12 and 18 who experienced neglect or abuse, victimization, and sexual assault, or those in conflict with the law. They may be wards of the state or waiting to return home, taken from their homes, or brought in by their families. The leader of our mental health team, a Jamaican born and raised psychiatrist at Yale New Haven Hospital, reviewed medical charts that were available during each of his visits; some of the girls had been treated by local care teams and diagnosed with developmental disabilities and/or mental illness. Our team leader further assessed them to determine their current needs. A temporary home, 46 girls were in residence at the time of our visit. Our theme for the week was the Time in Between-looking at life while at Homestead, having survived the past, and now preparing for the future.
Back Backgr ground ound Jamaica Jamaica is the third-largest island of the Greater Antilles in the Caribbean. The tropical country is divided into 14 parishes with Kingston as its capital (Black, 1994). According to a recent census, Jamaica's current population is estimated to be over 2.9 million with close to 40% living in Kingston and an overall poverty rate of 14.5% (Worldpopulationreview.com, 2019). The economy is slow growing, despite the popularity of the area for tourism. There is a stark contrast between the wealth in the vacation resorts and the poverty in some surrounding neighborhoods.
We were caught off guard by this at times-a mix of culture shock and ethnocentrism that left us wondering how our own biases might impact the work we were doing there. As a music therapist with a humanistic orientation, I consider myself to be nonjudgmental, to employ unconditional positive regard and I felt that my work with the girls reflected that philosophy. I realized, however, when reflecting on our experience for the purposes of this article, I was expressing biases and perhaps subconscious judgment. My perspective was naturally clouded by my own life experiences-though vast and diverse-as a white middle-class American. My own childhood faced challenges with family health and stability, financial insecurity, and occasional antisemitism, yet there was always a close-knit community of friends and family, a set of loving arms, a roof over my head, clothes in the closet, and food on the table, which I took for granted. I had some assumptions that many of the girls had none of those comforts, yet I learned that was not entirely accurate. I was both envious of and surprised by the ability to live off the land surrounding Homestead, with varied interpretations of community and wealth. Jamaica is full of natural riches such as fruit and nut trees, and scenic beauty with beaches, rain forests, and mountains. It was heartwarming to see how the staff at Homestead took pride in sharing a meal with us that they had prepared from the natural resources surrounding them.
Nationalism in the Caribbean emerged in many ways, with music playing a vital role in ideological cohesion and national identity. Song lyrics and musical rhythms helped frame Jamaican independence and freedom from colonial rule, giving voice to a collective identity (Lewin, 2000;Sutton, 2002). The Jamaican national motto "Out of Many, One People," encompasses the diversity on the island while defining its unity and national pride (Klein, 2018), and can be seen reflected in Bob Marley's "One Love." While studying many of his songs before our trip, I learned more about Marley himself, such as his mixed heritage. He was rejected by his father's (white) family and initially distrusted by the Black community, though his music came to serve as a way to unify the people, influencing a sense of solidarity, and fostering social cohesion. The music of Jamaica holds tremendous value in family, religion, social interaction, entertainment, and truly helps to define its culture. Musical styles specific to the spirit of the island include calypso, ska, dance hall, and reggae-the "heartbeat of the Jamaican people" (Lewin, 2000, p. 26).
Marley's "Redemption Song" has served as an anthem of sorts, inspired by local activism, providing a sense of unity and power with the message of emancipation (Caribbean Times, 2019). Before its independence in 1962, Jamaica was a British colony for over 300 years, influencing the language, education, socialization, economy, and the arts. "One negative result of this has been the development of a belief in the superiority of cultural expressions of other societies, particularly those of the former colonizers, and the inferiority of the indigenous traditions" (Lewin, 2000, p. 35).
As we explored music with the girls, we became more and more aware of our own expectations of what we might consider an appropriate expression or response. We were startled now and then by their boisterous musicking. While navigating the echoing acoustics and often other distractions in the main space at Homestead, we found ourselves wondering why so many of the girls appeared to be yelling rather than singing. Upon further reflection, we realized we were all singing loudly in large part to help drown out everything else and focus on the music itself. We also discovered that the girls were singing with such passion, with such intensity, with such freedom, that the music provided them with an outlet beyond any other, and the significance of the connection through their voices and their movements in the music was palpable. It was not only appropriate, it was essential. I too felt liberated, stepping out of my own boundaries and into music from my culture and theirs with new feeling, new understanding. We were consistently inspired by their sudden use of the chant and the theme song we introduced to them, a unifying and calming force, even when sung at the same volume or intensity as other songs. Sutton (2002) explains that music profoundly shapes the goals and objectives of a people moving toward a collective identity, cultural nationalism, and political independence.
While the people of Jamaica includes many ethnic groups, with the majority being of European and African descent, English is Jamaica's official language with variations that include British English to Jamaican Creole, or Patois. According to Lewin (2000), Jamaica is the most Africanized of the Caribbean islands, which is noted in the traditional dancing and drumming deeply rooted in religious rituals and ceremonies, and present in the social music scene. Marley's "No Woman, No Cry" was written to give women hope despite the challenges they face seeking social equality (Caribbean Times, 2019). The history of slavery and colonialism impacted not only the national identity but also gender discrimination in the country-a primarily patriarchal society where men are providers and women and children are historically dependent on them (Lewis & Carr, 2009). This perspective has been reinforced by religious and political structures that have, at times, led to an increase in women engaging in sex work in order to provide for their families (Chevannes, 1992;Moses-Scatliffe, 2012).

Culture
Although I had worked with this general population (female survivors of domestic violence or victims of sex crimes and teens with mental illness) in the past, I experienced some culture shock as I oriented to the new environment: both the natural surroundings of Jamaica and the Homestead facility itself. Levine and Adelman (1993) refer to culture shock as the feeling of confusion and disorientation that occurs when an individual leaves a familiar place and shifts to an unfamiliar one. In addition to the extreme heat and humidity outdoors, the chaos of the ongoing motion and reverberating sounds indoors led to a need for support among our team during our brief adjustment phase. It also took some time to become familiar with how we perceived the girls' accents and their use of Patois. We found that we were still able to connect in the music, even if we were not speaking the same words. "Mutual language can help to create bridges but does not create a 'barrier for musicking'" (Navarro Wagner, 2015, p. 35). Music did become our common language. Stige (2002) states that "both physical objects and meaning systems such as language and music are understood as artifacts…passed down from generation to generation" (p. 327). Music is believed to be a significant and highly regarded artifact in Jamaica. Early formulations of cultural studies referred to culture as "that complex whole which includes knowledge, belief, art, morals, laws, custom, and any other capabilities and habits acquired by man as a member of society" (Tylor, 1871, p.1). I have often heard music, television, magazines, and the like referred to as artifacts in American culture as well. These can be viewed as material aspects that help to support a local or global economy and can define a culture, or even a subgroup of society. As a treatment team at Homestead, we were working within a subculture as well-the community within the safe house itself and the surrounding yard with its intended security of the barbed wire, locked gates, and 24/7 guard. Kohls (1984) defined culture as: An evolving, integrated system of learned behavior patterns that is characteristic of the members of any given society. Culture refers to the total way of life for a particular group of people. It includes what a group of people thinks, says, does and makes -its customs, language, material artifacts and shared systems of attitudes and feelings. Culture is learned and transmitted from generation to generation. (p. 17) Kim (2008) asserts that one's personal awareness of cultural beliefs and background is the key to understanding the dynamics of cultural relations and cross-cultural care. "Our own cultural background, usually passed on to us through our familial teachings, informs us as to how we see people and the world. Whether we recognize that we have a worldview or not, it exists" (Brown, 2002). This space for various perspectives and world views is supported by Stige (2002) who considers a culture-centered mindset essential in music therapy practice and indicates that there is no culture-free zone in this work. In a culture-centered approach, there is always an exchange of influences, and the different expressions from individuals of diverse cultures are encouraged. Cultural settings and social circumstances are embedded in the therapeutic context. In our work with the girls, we were aware of, and sensitive to, differences in ethnicity/race, spiritual and religious practice, music preferences, age, gender identity, sexual orientation, socio-economic status, and life experience.
The ability of practitioners to provide effective services to two or more culturally diverse client populations is referred to as cross-cultural therapy (Bigby, 2003). As described by Kim (2008) cross-cultural music therapy is the practice within the therapeutic relationship that involves two different cultural backgrounds and ethnicities. We were acutely aware of that relationship and of our cultural countertransference. I feel that with a highly developed cultural identity (I sit comfortably in my own identity as a white, Jewish, American woman) I have a stronger capacity for openness to clients from different cultures. As a therapist and a mom, I also have a strong sense of my role as someone who gives to and cares for others. It is possible that my culture shock appeared as judgement, and my role as a "helper"-my desire to be needed or my subconscious belief that I had more and therefore more to give-was perceived by the girls; I am sure it influenced my role in the course of treatment. We understood that our ability to fully explore and engage in Jamaican culture and the culture at Homestead itself, as outsiders and in such a short time there, was limited and not without biases, yet the intensity of the work fostered a sense of community and bond that aided in the therapeutic process. We were grateful to have felt welcome.

Mental Illness in Jamaica
For years, Jamaica has spent only 5% of its total health budget on mental health care (World Health Organization, 2017). According to the WHO Atlas (2017), per 100,000 people in Jamaica, there are 1.15 psychiatrists, 0.03 child psychiatrists, and 26.57 total mental health workers. The WHO explains further that mental health and well-being are influenced not only by individual attributes but also by one's social circumstances and environment, indicating additional challenges faced by adolescents and women. A 2010 study conducted among 13-to 15-year-old girls in a Jamaican school setting found that 25.7% of all participants admitted to suicidal ideation over the course of the previous year. The same survey found that 23.1% of them had attempted suicide at least once over the same time period (Wilson-Mitchell et al., 2014, p. 4731). A lack of specific data regarding adolescent suicide in Jamaica was addressed in a study released in 2012 in which researchers collaborated with Jamaican police to track suicide statistics and the correlating gender differences. The findings noted an increase in male suicides and a decrease in female suicides among the adolescent population, ages 9 to 19. A possible explanation for this pattern referenced "greater attention and watchfulness over girls and increased detection of problems before they escalate to suicide" (Holder-Nevins et al., 2012, p.519).

Trauma
Derived from the Greek word for wound, trauma can be described as an emotional, psychological and/or physiological shock that causes damage, pain, or suffering in its lingering effects (Loewy & Hara, 2002;Stewart, 2010;Sutton 2002). In musical terms, trauma can be described as an interruption to one's rhythm or flow of energy and may lead to the immobility response-terror, horror, rage, and helplessness (Levine, 1997).
How trauma is perceived and addressed varies based on cultural norms, but the current Diagnostic and Statistical Manual of Mental Disorders (DSM-V) describes trauma as witnessing or experiencing directly or vicariously an actual or threatened death, serious injury, or sexual violence and includes a variety of stressors of varying magnitudes, frequency, and duration (APA, 2013). Vicarious trauma, often referred to as secondary traumatic stress or compassion fatigue, is salient for therapists working with survivors of violence, specifically sexual assault, including incest (Pearlman & Saakvitine, 1995), and relevant to our experience with many of the girls. The vast majority of the residents at Homestead had been involved in sex trafficking and/or had been victims of other types of sexual abuse and we recognized our vicarious trauma as caregivers which reflected that of the Homestead staff. During our short time there, we were navigating our own subjectivity, beliefs, and biases that we hoped would not negatively impact the treatment. I had prior experience as a music therapist working with young girls, adolescents, and women who had survived sexual assault-once, intermittently, and ongoing. I wanted to be sure that the girls did not simply view themselves as victims-as perhaps I did, or they may have believed I did-but rather survivors, and resilient young women. I admired those who were pregnant for following through with prenatal care. The nurse and midwife on our team provided some prenatal care and found local resources for the girls who needed ongoing care. They would be bringing new life into the world and, whether they would parent the child themselves or not, I felt it spoke to hope for their future.
Jamaica is a land rich in natural resources and we were working to foster resilience, to help the girls find their natural inner resources as well, so they could draw upon their own strengths in times of need. Many of the girls lived transient lives to some extent, moving from home to the streets or to foster care, sometimes running away, moving to Homestead, knowing this was just another stop along their journey. In our sessions where we sang and then discussed songs and analyzed lyrics about home, life, challenges, support systems, and future plans, some of the girls were vocal about their personal journey. They named family members who would be offering them a place to live, ideas of jobs or careers they wished to have, and the skills they would acquire to be successful. Some of that was happening already through their schooling and programs at Homestead. They were attending court appearances to clarify their next steps, either with parental support or acknowledging their separation into adulthood, welcoming support from their staff members and digging deep into their own desires to live differently than they had been. There was also talk of God providing them with strength and guidance.
Our theme for the week focused on this transitional time living at Homestead as an opportunity for the girls to develop the tools they would need to move on, emotionally and physically. Their ability to move forward would require resilience, which takes time and intentionality. The cultivation of resilience can help in the journey of recovery from past traumatic events. Resilience can be defined as "the process of adapting well in the face of adversity, trauma, tragedy, threats, or even significant sources of stress" (American Psychological Foundation [APF] & Discovery Health Channel, 2013).
The Caribbean Institute of Mental Health and Substance Abuse (CARIMENSA) explored resilience, defined in part as "the manifestation of positive adaptation despite significant life adversity" (Hickling et al., 2009, p. 32), in what the researchers described as an inner-city school setting in an impoverished and violent area of Kingston, Jamaica. During this study, 50 nine-year-old children, identified by the authors as struggling both academically and behaviorally, were split into a variable group and a control group. An intensive program was instituted within the variable group in which students received support designed to foster independence and resilience. This treatment included nutritional assistance, remedial math and literacy, and group psychotherapy that used creative methods such as art, music, and dance. After the program concluded, dramatic improvements in behavior and cognitive abilities were recorded within this group alone. Although this study was limited in scope, the results demonstrated promise for the benefits of cultivating positive traits in some of the most difficult circumstances (Hickling et al., 2009). The authors indicated that many schools would benefit from such services, although the Caribbean Institute was challenged by budget cuts and required alternative funding from both local and overseas sources to move forward.
The residents of Homestead have benefitted over the years from similar services. Though continuity of care has been intermittent, donations and volunteerism have helped to fund a computer program, garden, cosmetology training, general schooling, and all the services we provided. Our mental health team, over the years, noted similar advantages for the girls in cultivating their strengths and promise for their future, thus expanding the team. Even though trips were cancelled now and then due to unrest or illness in the area, they were ultimately rescheduled. This was a source of motivation upon planning for the work-that not only could each day with the girls bring them joy and strength to that single day, but that our short time with them could provide ongo-ing motivation and inspiration to move forward in their lives. One of the songs we sang with them often was "Free to be Me" by Francesca Battistelli. It speaks of resilience and hope, belief in oneself, and finding one's positive traits even among our "dents." It speaks of support from others which could include therapists, teachers, friends, God, as well as music and support from within.

Music Therapy and Trauma
"As trauma is an experience of life, so is music" (Borczon et al., 2010, p. 55). Group drumming, according to Bensimon et al. (2008), provides a myriad of benefits: sense of openness, togetherness, belonging, sharing, closeness, connectedness and intimacy, non-intimidating access to traumatic memories, outlet for rage, and regaining sense of self-control (p. 1). In our work, we witnessed this expression and regulation firsthand; we also saw how drumming brought out rhythms and movements that reflected traditional Reggae and Ska, expressing a rich connection to Afro-Caribbean culture. No translation was needed, and words became inconsequential. Sutton and De Backer (2009) state that "Music goes beyond the kinds of conceptual meaning that could be captured in words, but which may underlie words. Music has a unique quality that enables direct access to an affective and corporal aspect of the human psyche" (p. 75). Again, music became our common language, our link, a field of shared experiences and cultural insights, and our doorway to a new perspective.

Homestead
Originally a boy's facility, Homestead's consistent mission has been to create a stable, supportive, and nurturing environment for those who have experienced trauma in their lives. They work to achieve this by providing "intervention and rehabilitation that will ultimately build resilience in the girls, and aid in their socialization" (Orphaned Starfish, 2016, p.1). A few go out to school, while most are "home-schooled" with teachers who come to the facility. A cosmetology program, computer program, and vegetable garden have been gifted to the facility over the past several years, with intermittent financial and educational support, in an effort to provide the girls with skills leading to potential employment upon discharge. None of the aforementioned programs were active in 2016, although a new computer instructor had been interviewed and preliminarily hired with a tentative future start date. The empty structure used previously for the cosmetology program was affectionately referred to as the "beauty room" and used as one of our group therapy spaces.
My music therapy colleague who was on the team two years later shared that most of their sessions were held outside at a different facility; the girls (some of whom I had worked with as well) were in temporary housing due to renovations at Homestead. According to the Jamaica Observer (2019), over 20 million dollars from the Jamaican Government and the Child Protection and Family Services agency was put into transforming the facility. In the article, the CPFSA CEO indicated that it will be a haven for girls. "This facility will be a symbol of hope and inspiration, one that we will always be proud of-a place where our girls can live comfortably, while being equipped with the requisite skills as they prepare to make bold steps into the future" (Jamaica Observer, 2019, p.1). The junior minister of education commended the staff for their work with the girls, encouraging them to continue protecting and promoting their rights, to remain patient and kind to the girls while instilling discipline with love. He said, "we know some of the harsh realities that our children face, and in order to help them overcome trauma suffered, we have to be positive influences in their lives, and provide them with the necessary support" (Jamaica Observer, 2019, p.1). A new playground, picnic area, and outdoor athletic space were included. I could not find information about the current status of the cosmetology space or the computer lab. This does leave me to wonder about the benefits of such programs donated and then seemingly forgotten, and how the new facility will be preserved. It also gives me pause, hoping that the work we did with the girls, now on hold due to COVID-19, will be continued regular-ly, providing them with strength for their future and that the work with the staff will continue to foster resilience.
What struck me initially, when arriving at Homestead, was the large sign outside the main gate reading Homestead Place of Safety. I did not expect the location for this type of facility-a safe house-to be public. As a music therapy student many years earlier, I did clinical training at a safe house in Ohio for women and their children who had experienced domestic violence-the address was private and there was no sign outside the house which I thought was typical, but was quite the opposite in this situation. Homestead has also been written up in the Jamaica papers indicating its purpose, location (exact address), and its flaws. "House of horrors: Children in need of care and protection get culturized [sic] by the ones who are in conflict with the law, and the ones who can't help themselves get beaten up by both sets" (Jones, 2014). Not having seen this article until after our trip, I did not have this preconceived notion of Homestead or the residents. We had met as a team and discussed the needs of the girls, prepared our curriculum and materials, and I had begun to expand my musical repertoire accordingly. While there were challenging behaviors and there was culture shock as I reference in this article, I would certainly not describe Homestead as a house of horrors and appreciated not having had this assumption of the situation in advance.
Homestead services "at-risk" teen girls, a global term describing youth who may be in jeopardy due to school truancy, poverty, neglect or abuse, stigma surrounding mental illness, lacking skills needed for employment, or other concerns leading to challenges transitioning into adulthood. For the girls at Homestead, the most prevalent risks seem to include all listed above, leading to significant challenges transitioning to independence, perhaps due to lack of support at home or from family. For a few of the girls, risk factors also included their pregnancy, with ongoing need for both mental health care and medical care. Oversight at the facility is provided by the Child Development Agency (CDA) and Centre for the Investigation of Sexual Offenses and Sexual Abuse (CISOSA), yet sometimes the girls do not return safely from school or court appearances. According to the staff on site, some of the girls reportedly engage in or are forced into occasional sexual activity with offsite neighbors. There is a men's boxing gym across the street that, to me personally, seemed potentially unsafe for the Homestead residents who go offsite. According to Chevannes (1992), male dominance is a point of consensus regarding socialization and sexuality in Jamaica, and adolescent girls are said to be at a disadvantage, most reporting their first sexual encounter to have been with an older male. "Church and Bible provide the ideological, and the family and community the practical, justification for female subordination to males" (Chevannes, 1992).
Due to challenges in their personal lives outside of Homestead and their limited freedom at the facility, the girls had not all experienced typical childhood play required to develop strong executive functioning and a prosocial brain. Barbed wire was all around the locked fencing surrounding the facility, in addition to a 24/7 security guard. Despite my previous work in inpatient and day treatment adolescent psychiatric settings, I was taken aback by the front entrance to the main building, the gates behind which the girls were locked throughout most of their day ( Fig. 1 & 2). We were informed this was for their own protection and for liability purposes as the girls need to be accounted for each day. During a song discussion in a small group music therapy session one day, one of the girls (Sheela, introduced below) described herself as "living in a paradise and a war zone." My initial thought was her environment: the locked gates leading to the worn yard with a broken basketball hoop and partial swing set, while also full of fruit trees, looking out over the barbed wire fencing to the glory of the Jamaica mountains (Fig. 3, 4 & 5). Reflecting further, working through my own cultural biases and cultural empathy, I recognized this polar extreme was truly a reflection of her current situation in transitional housing and personal experiences as an adolescent girl, navigating relationships and responsibilities in preparing for her future.

Celebrating the Residents at Homestead
This is just a snapshot of some residents at Homestead and their involvement in music therapy during our short time with them, and the descriptions below are naturally colored by my personal perspective. "Because we observe client behaviour through our world view, we often judge and/or attempt to explain their behaviour from our own view" (Brown, 2002). My hope is to have provided a picture of this transient community and how the girls appeared to bond with each other, and with us, in this short time through music. In this article I have changed the girls' names to protect their identities. Sheela displayed aggressive behaviors and often appeared angry outside of music therapy sessions. She was observed attempting to throw a chair toward a peer one morning. The music then seemed to help her regulate and she became a strong, active member of the group. She participated in group singing and drumming followed by song discussion. Sheela described her life in and out of Homestead, her goals for the future, and shared the honest expression of living in a "paradise and a war zone." Celine really connected with us. She shared several fears with me and then with our team leader (psychiatrist) as encouraged. She also shared having been sexually abused and having a psychiatric diagnosis. Celine required meds but was no longer taking them reportedly due to lack of accessibility. Music therapy groups appeared to provide her with a sense of purpose, support, and comfort. Serena (Fig. 6) had scars on both cheeks, reminiscent of a tear-streaked face. She usually wanted to help carry and set up instruments, loved drumming, and while she didn't speak very much, she often began singing our chant or the theme song spontaneously, in times of calm and chaos. Going back and forth on her stomach on the stools with wheels in the beauty room seemed to ground her, and she kept moving even while remaining engaged in our group process. She appeared gentle with an aura of calm about her but was also quick to fight with the other girls, usually in attempts to intervene when others fought. During one of our team meetings, she looked in on us from outside eager to make positive connections.
Brooke was a leader; she was very connected to the treatment team and open to creative expression. Her participation in group naturally served as a model for the others.
Monica was quiet and reserved but surprised us by sharing a solo song during a group session. She also shared past suicidal ideations and appreciation for her strong connection to the arts as a way of healing. Sam was bullied by others, "boxed" at night, as they described it, so she was not sleeping well and occasionally fell asleep during the day. She had been given a psychiatric diagnosis and presented with a variety of mental health concerns. She often approached the other girls with complaints about them, leading to social isolation. During our sessions, Sam engaged musically and requested to sing solos, which appeared to provide her with grounding, connection, and self-confidence.
Janet was eager to participate in music therapy each day. She was engaged in song writing, singing, and drumming. One of the leaders in a lyric rewrite for our theme song, Janet also recorded her voice singing it with my grad student accompanying (Video 1).
Jewel (Jane Doe, Fig. 7) did not speak, perhaps selectively mute due to trauma, but no one seemed to really know. We were uncertain of her level of cognition as her response to others and overall communication was somewhat limited. She used a combination of American Sign Language (ASL), her own signs/gestures, which may have been part of Jamaican Country Sign Language if she had ever lived in or with people from the south western parish of St. Elizabeth, and some Jamaican Sign Language (JSL, which was derived from ASL). She wrote her name on her nametag the first day, and then after calling her that, some of the girls said her name was Jane Doe-as labeled on her backpack. She apparently had been living in another facility previously, but it seemed her name was not known there either, as her files that followed her to Homestead were labeled like her backpack. I admit that stirred emotion in me, and I felt her connect with me daily through our mutual understanding of and communication through sign.
Valerie was called Rambo by the other girls and described by them as "sick upstairs." The team agreed she presented with psychotic behaviors. A few times she was seen throwing rocks at the outside of the beauty room while we were in session. Other times she briefly attended and engaged in the music, seeming connected to the group process for moments at a time.
Alexandra had a sweet smile, engaged musically with the group and sang with my grad student 1:1. However, she had very slow responses, the cause of which we were not sure-perhaps a developmental delay, shaken baby syndrome, and/or trauma related PTSD.
Grace just wanted to be with us. She was sweet and soft spoken, quietly participatory, gentle, and kind. She seemed drawn to the music and appeared to feel content Drumming groups in the beauty room during music therapy in the space. She was present and quietly engaged in every music therapy session we offered.
Dana was filled with so much joy when she was drumming. One day the staff would not allow her to join the afternoon session because of some behaviors during lunch, so we worked with them to explain how this was therapy and not to be taken away as punishment. The next day she was able to participate and was once again filled with joy which lasted throughout the day and benefited everyone around her.

Music Ther Music Therap apy y
Each day began with a full group chant followed by deep breathing, stretching, and/ or guided meditation with music. As a professional team we alternated leading and supporting the morning routine. The girls were then split into smaller groups to move between music therapy, art therapy, social work/journaling, and 1:1 time with the psychiatrist, psychiatric nurse, or midwife before and after lunch. We usually ended each day with a full group drum circle and song share, though the schedule did change throughout the week due to weather or other things that required groups to converge and resulted in more interdisciplinary work. Given our differences and the newness of our relationships, I was inspired by the way the girls and the staff took to music therapy. They were open to sharing familiar music while also learning songs that were completely new to them. They took great pride in sharing music from their culture, often choosing to sing a solo or make a request during a group song session, and we were all pleasantly surprised whenever we discovered some mutual favorites, giving us common ground. We had also found popular American songs that had been recorded by Jamaican musicians, such as "Hello" by Adele re-recorded by Conkarah, a popular Reggae artist from Jamaica.
The music and the space we provided appeared to foster a sense of safety and community. The girls worked together cooperatively and cohesively to create drum rhythms, request songs, and rewrite lyrics. They redirected each other's complaints or unkind words and even supported each other during emotional verbal processing of song lyrics relating to their own lives, fears, hopes, and dreams. While it was clear that music was a natural part of their daily lives in various ways, the Homestead staff became more and more involved with the girls in positive ways throughout the week, engaging in music with them and using a more conversational rather than confrontational tone of voice.
Singing helps to release endorphins that trigger a positive feeling in the body, reducing the perception of pain. In medical and rehabilitation settings, this often means a decreased need for morphine or other pain medications. At Homestead, it was apparent that singing, and music in general, provided mood elevation, a boost in self-esteem, and decreased anxiety leading to more positive interactions and motivation to engage. Through group singing and drumming, the girls also experienced a sense of belonging, cohesiveness, and teamwork as demonstrated by their cooperation and en- Lyric rewrite of theme song above the banner created in art therapy gagement within the musical space. Girls who could not sit beside each other during a meal, or had no previous positive interactions with one another in their typical day, were able to work together in music therapy during lyric analysis, drum circles, and song writing. Engaging collaboratively, their song writing became progressively more supportive and positive-from writing about being in a prison to an abandoned house to, finally, a "better place." Our theme song, "The Time in Between" by Francesca Battistelli, was chosen to reflect the overall theme for the week and became a source of comfort for them. At any moment, especially quiet times and times with tension, the girls could be heard singing the original version or their rewritten one (Video 1; Fig.  11 and 12).

Video Video 1 1
One of the girls (Janet) singing our small group rewrite of the theme song with my music therapy graduate student from Molloy College playing guitar. There is something so moving about the imperfection in this resident's pitch and tone as she freely expressed herself through the song. Video: https://www.youtube.com/watch?v=UCshEta1vQg Starting out the day with deep breathing and chanting a positive message ("Oh what a day, what a day we're gonna have today!") helped to set the tone for group work, and returning to the chant throughout the day served as a distraction from cursing at and intimidating each other. During the chant and other music experiences, fewer girls joined fights when one or two who were already disengaged became aggressive. Sheela, who described her life as a paradise and a war zone had, only 15 minutes before a session, been expressing anger and attempting to throw a chair. The music therapy group was about to begin, and once calmed as the music started, she engaged in powerful music making for the remainder of the day; she was even able to maintain control in session during a brief dispute with a peer. At times of chaos, some of the girls engaged in regulatory behaviors, such as thumb sucking. During music therapy, self-regulation appeared through musical engagement and reciprocal play with peers. With issues regarding self-esteem, self-worth, and poor body image, the girls often expressed themselves through anger with difficulty regulating. In one tense moment, I began singing "I am beautiful, I am beautiful and so are you!" to the tune of "Marching in the Light of God." Without missing a beat, there were suddenly girls singing with me and/or drumming along. There was an immediate, clear boost in self-esteem, selfworth, and developing support of one another as evidenced by their positive changes in facial affect, vocal strength, and cohesive, spontaneous, and improvisational music making.
Later on, adding American Sign Language to the song provided the girls with a sense of accomplishment and was something they could help teach one another while demonstrating to us their pride in having learned something new. The manual language was also another form of self-expression, emanating from their natural draw to use their bodies as a vehicle for communication; the sign language allowed them to do so in a safe and responsive, meaningful way. Coupled with music, signs were easily learned, remembered, and shared. This combination provided an ease of self-expression and opportunity to connect more deeply with one another, especially with Jewel, who relied on sign language for her own expressive communication. Jewel remained engaged for longer than usual during this particular group session.
Cline (cited in Schrader & Wendland, 2012) stated that since "music is processed holistically at the brain stem, mid-brain and cortical levels, music activities can be designed to elicit behavioral or physiological changes that do not require the use of higher-level cognition or language skills" (p. 392). However, while the staff and residents at Homestead had suggested that Jewel had cognitive deficits and developmental delays, I found through our conversations in sign that she appeared "typical" in relation to the other girls. In our music therapy sessions, the incorporation of ASL and JSL, full languages in their own right and utilized fairly well by Jewel, appeared to provide her with a sense of belonging while fostering a new perspective and empathy within the community.
Naturally moved to dance, the music therapy setting gave the girls a safe space without sexual connotation. Traditional dances in many cultures reflect ritual, sexual, and spiritual movements; in recent years, daggering has been seen in Caribbean dance halls, a style of dance also referred to as dry sex. Some of the girls had been involved in sex trafficking and some had experienced sexual abuse, so this opportunity to move freely and safely with trusted adults, if they chose to participate, may have been essential for their autonomy, self-image, and self-worth.
During one session, this led to a childhood playground game incorporating hand clapping with partners that fostered a sense of innocence and palpable glee. Our music therapy graduate student was invited into this play time, demonstrating a sense of trust and much needed nonthreatening companionship. It was a truly poignant moment. We were aware of and at times concerned about childish behaviors some of the girls resorted to in an effort to self-soothe, such as thumb sucking. While sucking one's thumb can release stress and provide comfort, it can also lead to dental issues and stigma, or limitations related to emotional maturity. In contrast, this childhood game allowed the girls to find joy and empathy with peers in ways they may not otherwise have been able to due to their life experiences. The interactive, playful engagement provided a sense of community that could be replicated and help support them outside of Homestead.
Requests for songs such as "Lean on Me" led us to discuss with the girls who they could turn to in times of need and places where they felt protected. Answers included select staff and one or two other girls but primarily people and places outside of the Homestead gates, even outside of Jamaica altogether. Yet despite the lack of trust amongst the residents of Homestead, singing songs like this together provided-once again-a sense of belonging and acceptance. They were open to sharing and listening. A true sisterhood appeared, eliciting genuine smiles, eye contact, and even friendly affection.
The girls verbally expressed gratitude for the staff now and then, and were the occasional recipients of nurturing affection. However, the boundaries were not always clear. Homestead is understaffed although the staff on duty aim to fully meet the needs of the girls with regard to their nutrition, education, and socialization. Upon request, members of our team provided support and professional development to the staff almost daily during our time there, while the girls participated in group and individual therapy. There was deep appreciation expressed for the new perspectives and ideas shared. Girls at Homestead after a music therapy session Schrader and Wendland (2012) discussed the vital role of care for the caregiver in preventing burnout and maintaining overall health. They cited a survey of counselors working with victims of sexual abuse to determine strategies for work-related stress. The results indicated the importance of self-care, including engagement in music and other expressive art forms. At Homestead, there was a noticeable difference in staff demeanor and interaction with the girls on Thursday, near the end of our week together, as compared to the prior Sunday when we had just begun.
Together they had engaged in guided meditation, group singing, counseling, and were grateful for the opportunity to learn how to more positively meet the needs of the girls in their care. Music played a pivotal role in this change. With guidance from the music therapy team, the mental health team leader (an accomplished Yale psychiatrist of Jamaican origin) taught "Dona Nobis Pacem" to the staff. This became their contact song (Boxill, 1981), providing safety, cohesion, and comfort in their training sessions. Much like our theme song and chant with the girls, the staff and our team also returned to this contact song in times of need, leading to even more group musiking. The staff later shared that song and joined in others with the girls through a group singing and drumming experience.

Video Video 2 2 & & 3 3
Staff and resident groups singing and drumming to "Rivers of Babylon" and "One Love" demonstrating a high level of group cohesion and mutual support. Video: https://www.youtube.com/watch?v=E-p5iUPKAGQ Video: https://www.youtube.com/watch?v=7394WqGF73I Interdisciplinary work was beneficial for the professional team and the clients alike, especially in easing some of the challenges during our time at Homestead. Along with the art therapist, we created handmade instruments with the girls that we later used in group music making; a mural that was made during art therapy helped inspire song writing and improvisation; group singing and drumming was recorded and accompanied an end of the week slide show. We worked with the art therapist in helping the girls design flip flops we had brought for them and assisted the social worker with music-mediated meditations and journaling. The psychiatrist occasionally joined us in small groups throughout the week, providing his expertise with his shared culture by helping to translate the Patois, as well as helping to guide any major, unrelated conflicts or outbursts back to the music. As music therapists, we also helped with song choices for the social worker and psychiatrist to include in morning meditation and mediation with the facility staff and daily routines. We had prepared a repertoire of traditional music from the Caribbean in general and Jamaica specifically, in addition to songs popular with teens in both Jamaica and the U.S. We brought a songbook for the girls that consisted of lyrics to many of those songs and several others that we wanted to introduce to them, such as our theme song for the week. As a whole, they were eager to share their preferences and appeared to appreciate each new song we shared, as they listened, sang or drummed along, discussed lyrics and requested to learn more.
The girls had a tremendous impact on our experience and the music therapy process. Some engaged so powerfully, but we did not know all their names. Between the large and transient groups, several names that were new to us, the loud environmental sounds and poor acoustics in the space, unfamiliarity with the cadences of their speech, and the loss of name tags, we were sadly unable to learn or remember them all. This created a strange dichotomy, feeling such a strong therapeutic relationship given the short time working together yet hardly knowing them at all. Of the 46 girls in residence at the time, about 40 participated in large group music therapy and 20-30 of them engaged in smaller group work at various times. Occasionally we had 5-10 in a session where deeper and even more intimate work was able to take place.

P Pr rof ofes essiona sional R l Refl eflections ections
This was truly intimate work. The girls opened their world to us; they invited strangers into their lives when trust was an issue-some afraid to trust, others knowing they trusted too freely. They embraced unfamiliar music and new experiences we offered to them; they expressed joy in our commonalities. While we were addressing significant issues, our being there for only five full days meant we had to be aware of the risks of re-traumatization. The depth of our work was limited in that respect, yet the power of the work remains palpable. The short length of our time together also impacted our ability to fully appreciate and understand the culture of Jamaica in general and Homestead more specifically. It was my first time in Jamaica, and while I had experience with music therapy in adolescent psychiatry and in shelters for domestic violence, this experience was new territory for me. I had to deal with my own emotional responses to being away from my family, the culture shock and the empathy, in addition to the distinct culture of this particular facility and group of girls. I had to address it each day before I could be my best self in sessions. Fortunately, our team was comprised of professionals who both needed and could provide support to work through these moments. We engaged in group meditation and group singing; we also processed the sessions and discussed the residents on a daily basis. The team bond was essential, leading to the special work we did both independently and together. I was grateful to my student as well-while I was there as her supervisor and I know I helped to guide her experience and growth, she had previously been on a different music therapy fieldwork trip in Jamaica so she could offer some familiarity as a result. Working in such intimate moments, supervision lines get crossed as well, and my student became my partner. I was proud of her and grateful for the work together. To this day, we can talk about specific moments from that trip, from the work with the girls, and we are immediately transported back in time. Those five short days transformed my life in many ways, impacted my continued work as a music therapist, and gave me perspective. It was powerful. It remains difficult to fully put into words. This poem is one way to describe it: Music. Natural expression from the heart. A window into the soul. A reminder of yesterday and a glimpse of tomorrow. Reflecting pain, peace, and all that's in between. Beauty of togetherness in the wake of torment. Paradise in a war zone. Music. A safety net. A cocoon, a bubble. Encouraging self-expression in time of need, Cohesion when the world is at odds, organization in the midst of chaos. Harmony. Opening doors to happiness, success, safe love and renewed life. Music. A sense of belonging, belief in oneself and each other. Acceptance. Possibilities.

C Conclusion onclusion
This paper contextualizes the first music therapy program within the mental health team as a part of the Molloy College Short-Term International Health Mission (STIHM) with PRN Relief International and the Dominican Sisters in Jamaica, servicing residents at Homestead House of Safety. While the trip is planned twice each year, and we have been fortunate to have had three other music therapy clinician/student teams from Molloy College in attendance since this first trip, it has also been cancelled three times between 2016 and 2020: once due to unrest in Kingston, once due to an outbreak of the dengue fever, and most recently, once due to the Covid-19 virus and travel bans. Continuity of care remains a concern. During the dengue fever, the psychiatrist who leads the mental health team was able to travel to Jamaica along with the art therapist and a music therapist from their hospital to work closely with the Homestead staff for a short period of time. Construction and renovations at the facility moved the residents to temporary housing-they remained together but may not have yet been able to move back to their more familiar, more permanent home. In addition to the purpose of providing ongoing biannual care, the team has been compiling curriculum, materials, and resources that can be implemented in other communities in need. There is hope that the United Nations will adopt and support the program, making it more accessible to those communities. I am personally grateful that music therapy has been incorporated in this work outside of the US where services are not as readily available, and I hope to help expand the literature in this area. As our team continues to provide services at Homestead along with my music therapy colleagues and our students, I am optimistic that the benefits will have an even greater impact and the literature will grow to reflect that work.
Special thanks to Lillie Klein MT-BC, LCAT.
About the Author About the Author I appreciate the opportunity to share my experience in music therapy! I've worked with clients and patients in a variety of settings including NICU, early childhood special education and Deaf education, pediatric medicine, pediatric hospice, child and adolescent psychiatry, and nursing homes. For the past 25 years I have supervised music therapy students from Molloy College (and other programs) in their clinical training, and I'm in my 10th year on the staff and faculty in the music department at Molloy. It was an honor to be part of the mental health team with the Molloy Mission and I hope to have another opportunity for this work. I feel strongly about advocating for music therapy and spent a few years on the New York State Task Force for Occupational Regulation. I am especially passionate about family centered work. 21 years ago I opened my own practice, Baby Fingers, servicing families and children where we focus on relationships and language development through music and sign language. I have served as an expert for parenting programs, authored sign language books for kids in addition to music therapy articles, podcasts, and textbook chapters, and have presented at conferences both regionally and nationally. Lora Heller, MS, LCAT, MT-BC. https://mybabyfingers.com / https://www.molloy.edu