Music Therapy with Traumatized Refugees in a Clinical Setting[1]

By Jaap Orth

Introduction

In the past 20 years music therapy has been used extensively for trauma treatment. Most of the described methods of music therapy in trauma treatment deal with war veterans and victims of maltreatment or sexual abuse (Austin, 2002; Bonny, 1986). Music therapists connected to War Child, an organization working with children in war zones or in post-war environments, describe their experiences with music therapy in situations in which they have to deal with cultural differences and stress-inducing factors. They describe clinical examples and major themes emerging from the ways in which the clients experience their music therapy (Lang & McInerney, 2002).

However, a clear methodical account of music therapy in the treatment of traumatized refugees, with special attention to social and cultural aspects such as differences in musical interpretation and perception, in language, and stress inducing aspects caused by their present situation, seems to be lacking.

As music therapists now deal more often with traumatized refugees, and the demand for documentation, research, and a methodical description has grown, in this article I would like to make a contribution to the development of a methodology in music therapy with traumatized refugees.

Various methods used by music therapists in trauma treatment will be described. An overview of the development of a set of methods at Phoenix, a highly specialized inpatient treatment facility for refugees and asylum seekers, will be presented and I will focus on four approaches I developed in my work with traumatized refugees.

Music Therapy and Trauma

Some of the intense effects of traumas on the person's body, mind, and spirit can be observed in the alternation between a state of "overwhelm and intense re-experiencing of the trauma, and a state of emotional constriction and numbing which can include avoidance of people, places and events that might trigger traumatic associations and bring on intolerable anxiety or panic" (Austin in Sutton, 2002, p.232). When these posttraumatic reactions continue for a long time it is known as posttraumatic stress disorder (PTSD). PTSD comprises three main groups of problems, which can be categorized under the headings of intrusive, avoidant, and arousal symptoms (van der Kolk, 1987).

Of frequent occurrence purposes of using music therapy for the treatment of posttraumatic complaints are to help clients (1) get into contact with and give space to actual emotions that are not dominated by trauma, (2) start the process of making existential choices, and (3) regain control over their own lives.

When dealing with intrusive and arousal symptoms, music therapists mainly focus on reducing the emotional stress and anxiety level, channeling or redirecting emotions via healthy outlets, and developing relaxation or diversion. In order to accomplish this, sleep-inducing tapes, relaxation through music, or other means are used to provide a way for a person to express his or her feelings in a safe way. Instrumental and singing improvisations are often used for this purpose.

Austin (2002) applies "vocal holding techniques" in her trauma treatment of adult clients, who suffer from the symptoms of childhood abuse, emotional deprivation, and inadequate parenting. This is a vocal improvisation method that she developed using two chords intentionally combined with her own voice. She does this to create a consistent and stable musical environment that facilitates improvised singing within the client-therapist relationship. This is also a way to develop social interaction and communicative skills to seek assistance and distraction through others as well as facilitating integration. Music therapists, when dealing with avoidant symptoms, stimulate an increased awareness of self, validating one's feelings and identifying emotions. For this purpose, forms of improvisation are offered, including singing and discussions and/or music, with room for associations to trigger memories.

In her music therapy with traumatized refugees Zharinova-Sanderson (2002) uses (folk)songs known by her clients from their own cultural heritage, in order to share memories and thoughts from their native countries and to strengthen their own identity. By way of the client teaching, singing, and performing his or her traditional songs, an easy link is created with the client's cultural identity and personal history. Zharinova-Sanderson explains that this helps the client to switch from a dependent role to the role of an expert.

Different Music Therapy Methods

In this section I look at some music therapy methods already in use in trauma treatment. I will describe vocal holding techniques, singing and discussions, and guided imagery and music (GIM).

Vocal Holding Techniques

One of the models that integrate speech in improvisation is vocal holding techniques, a method that Austin (1999) developed. In this model, the music therapist can integrate movement, speech, and drama. This method has proven effective in creating an opportunity for a safe, therapeutic regression in which dissociated and/or unconscious feelings, memories and situations can gradually be accessed, experienced, understood, and integrated. In vocal holding technique, an improvisational structure is usually limited to two chords in combination with the therapist's voice in order to establish a predictable, secure musical and psychological container that facilitates improvised singing. Austin finds the combination of improvised singing and verbal processing to be one of the most effective ways of working with the unresolved traumas of childhood. The method proves to be especially useful in working through developmental injuries and arrests due to traumatic ruptures in the mother-child relationship and/or empathic failures at crucial developmental junctures. The inner world of the traumatized clients contains split off, dissociated parts of the self, which are often externalized in the client-therapist relationship and can be worked with in the transference-counter transference situation (Davies & Frawley, 1994). In this method, the relationship field is enlarged to include transference and counter transference to and in the music. Austin (2002) states:

Vocal holding initially tends to promote a positive transference, that of the longed for good mother of early infancy and childhood. This highly empathic musical environment is fertile soil in which trust can grow and feelings can be brought to light. If the therapeutic relationship feels trustworthy enough, the traumatised client will begin to differentiate feelings such as grief, terror and rage. At those moments, the therapist and the music have to be experienced by the client as strong and resilient enough to withstand these intense affects. The therapist might alter the music somewhat to reflect the client's changing emotional intensity (Austin 2002, p.240).

Singing and Discussions

In treatment of trauma, singing can be restorative for a variety of reasons. Austin (2002) names three: on a physiological level, singing facilitates deep breathing; deep breathing slows the heart rate and calms the nervous system, stilling the mind and the body; and relaxation is the result. Singing is also a neuromuscular activity, and muscular patterns are closely linked to psychological patterns and emotional response. When we sing, internally resonating vibrations break up and release blockages of energy, which is particularly relevant to the traumatized people who have frozen, numbed off areas in the body that hold traumatic experiences. Austin quotes Levine (1997): " This residue of unresolved, undischarged energy gets trapped in the nervous system and creates the debilitating symptoms associated with trauma. Singing can enable the traumatized client to reconnect with his or her essential nature by providing access to, and an outlet for, intense feelings" (Austin 2002, p.235).

The act of singing is empowering: sensing the life force flowing through the body; feeling one's strength in the ability to produce strong and prolonged tones; experiencing one's creativity in the process of making something beautiful; having the ability to move oneself and others; and hearing one's own voice mirroring back the undeniable confirmation of existence. Owning one's voice is owning one's authority and ending a cycle of victimisation (Austin, 2002, p. 236.)

Austin's (2002) purpose of using singing in trauma treatment as stated here is especially interesting because she views it as bridging the division between mental and physical problems. In other cultures, like the African, this division does not seem as obvious. Therapeutic treatment in Europe and the United States is directed toward the integration of traumatic experiences in the psyche of the person requesting help. Criticism of present healthcare provisions focus, in particular, on strong verbal and individualistic biases, and on segmented and highly regulated structure (Van Dijk, 2001 p.34).

Singing and discussions are described on the War Child Web site - The Mostar Music Centre (2002). This method is used mainly by music therapists working with children in post-war environments. The music stimulates clients' responses to the lyric parts. Sometimes the music itself encourages the expression of thoughts and feelings associated with the songs. Typical procedures of this method might go as follows: The therapist usually opens the session by singing songs familiar to the clients. After singing several songs, the therapist leads a discussion related to the themes of the songs. Once each client has expressed and discussed his or her own thoughts, feelings, and ideas, the therapist improvises a song with the words from the clients. This can be a very positive conclusion of the session (in fact, the therapist tries to make the song positive) so that each client might carry over his or her feelings and emotions in productive ways (Website: Mostar Music Centre 2002).

Guided Imagery and Music

Guided imagery music (GIM) is a method developed by Helen Bonny (Bonny, 1986). The method is based on the basic assumption that it is indeed possible to select the most appropriate music for the client, depending on the therapist's understanding of the client's needs. GIM is often used to help treat severe posttraumatic stress, where, through imagery, a client is able to identify his or her fears and the traumatic events of the past. GIM refers to the use of music to stimulate a state of self-hypnosis, which is achieved through one's imagination. The act of listening to (classical) music is combined with a relaxed state of mind and body in order to evoke imagery for the purpose of self-actualization. The imagery a client creates is often representative of problems or difficulties in the client's life. The client can then take what he or she discovers and deal with unresolved issues, thus helping heal the mind and spirit. GIM does not intend to cure or treat symptoms; rather it is in search of a client's inner awareness to focus on and identify problems.

GIM can be used in the treatment of traumatized war veterans to help the client find his or her feelings again, which may have been isolated and numbed because of the severe trauma he or she has suffered.

Nevertheless, in the treatment of traumatized refugees GIM does not always seem practical to me, because in dealing with refugees from other cultures, it is often hard to find existing music that corresponds to the emotional state and needs of the client. My experience is that there can be great differences between the perception and interpretation of music in the various cultures. Furthermore, refugees often find themselves in situations which they experience as unsafe and stressful, so they cannot fully concentrate on the music and may even have strong resistance to do so.

Music Therapy From A Clinical Perspective

The Phoenix Centre

Phoenix is part of the mental health organization De Gelderse Roos in the Netherlands. This crosscultural center is a highly specialized inpatient treatment facility for refugees and asylum seekers. It serves as a "last resort" for treating resistant disorders, with special attention to social and cultural aspects in assessment and treatment. Refugees and asylum seekers with all kinds of psychiatric disorders (including culture-bound syndromes) are admitted, specifically those cases in which inpatient treatment in general mental health facilities fail to adequately diagnose or treat them.

Historical Overview

Since I started working in 1982 as a music therapist dealing with severely traumatized refugees, I adapted several methods, developed by colleagues for the work with traumatized refugees. I also experimented with new methods. This was necessary because in dealing with traumatized refugees, various aspects play a major role and have consequences for the treatment, such as: differences in culture, language, and stress inducing aspects caused by their present situation. After some time the obstacles, but also the advantages, of a music therapeutic approach became clear.

For example, I found that African refugees sing, dance and improvise considerably easier than refugees from western cultures. In Mid-African countries music seems to be an integral part of life and it is more important as an expression of emotions and feelings than as an artistic form. In comparison with our Western culture, there are often major differences in function, perception and interpretation of music and the way people express themselves in music. This enforces the use of non-Western musical instruments and music, different ways in playing music together, and knowledge about the effect the selected music will have on the client (Orth, 1992).

For this reason, I have developed and built musical instruments, which made it possible to improvise in a pentatonic way and play quarter tones. I also asked the clients to bring their own music.

Using the music the clients themselves bring, is an easy way to tune into their music culture and overcome the differences between our music culture and theirs. The therapist must submerge and be open to the other music; this is made easier with the availability of the Internet with access to examples of all types of music. Many traumatized refugees can clearly indicate what music they would select to relax by. In improvising music with Mid-African clients we more often play in question-answer form. Stress-inducing factors that traumatized refugees have to deal with play, a prominent aspect of music therapy. Clients often cannot start from a safe "home base" to digest the intensive reactions, which result from therapy. Anxiety concerning family back home or still in the asylum-seekers center, their residence permit, housing and discrimination make it hard to concentrate on the treatment and on their own development. Another aspect that hampers the use of music is that many clients find it difficult to cope with loud sounds, which are associated with the war violence they experienced at close hand. Loud sounds are also associated with executions and bombardments. Sometimes music was used while they were tortured and then music became part of the trauma. This fact was revealed when in one of my group sessions a woman had a flashback of the execution of her father when one of her fellow group members played a roll on a marching drum. Her father's execution, that she witnessed, was accompanied by the rolls of a drum. Because in this group therapy certain music can easily evoke intrusive memories, it is necessary to surround these sessions with plenty of safety.

In music therapy, not knowing the client's language is not always a hindrance. When using their mother tongue to express thoughts and memories doing musical improvisations, the clients seem to create a more fluid flow of words, while the therapist might not understand them. And in the evaluation of the improvisations afterwards, they can choose to be quiet or explain in a different way certain phrases they expressed in the improvisation. So the language gap is often advantageous to them and offers extra safety. Athough it is often not necessary to understand one another when making music together and playing instrumental improvisations, the language gap does make working together more complicated and causes limitations to the way the clients can make themselves verbally understood.

My impression is that because the shocking incidents that caused the trauma took place very recently, certain musical activities seem to increase resistance and tension, also because music was sometimes part of the traumatic experience or because the clients could not cope with loud sounds. In these cases, music can evoke such intense feelings, memories, and associations that it is scrupulously avoided. Above all it is hard to control feelings that are related to trauma. Besides a safe working environment, the methods used should be inviting as well as deemed safe by the clients. These approaches must include all possibilities to explore resulting feelings, to shape or reduce them, while at the same time producing a great desire to express and sometimes literally shout out these feelings. I often have to work between these two forces; on one side the extreme need to control feelings and on the other side the extreme need to express what is felt. In working with patients from various cultures, it is important to have sufficient knowledge of other cultures; not only about the different norms, but also the different opinions about "being ill" and how to deal with sickness.

The interpretation of "unhealthiness" can differ greatly between cultures. Limburg-Okken (1989) and Kirmayer (2002) give examples of the somatisizing of complaints. Three quarters of the world population experience complaints in a physical way. But in the Western world complaints often manifests themselves into a mental complaint.

Developing a Set of Methods

In Phoenix, I initially worked with relatively homogenous groups of Vietnamese refugees. I focused on enhancing their identities by concentrating on their culture. I studied Vietnamese music and the social meaning and the various means of expression this music could offer these clients. After 1995 it was no longer possible to work with these groups of homogenous Vietnamese refugees because refugees from many other countries started to arrive at Phoenix. The groups became heterogeneous and there was a need to concentrate more on integration and look for common cultural elements. Pop music seemed especially relevant to the younger clients in the target groups as music they could all relate to from their own cultural background. Some groups could be composed of as many as 10 different cultures: refugees from Somalia, Azerbaijan, Cambodia, and Chile were all part of the same group. For me as the therapist and also for the participants, it was often an extraordinary experience that in such a short time, sometimes as quick as 15 minutes, it was possible to play, sing, and dance together with such a diverse mixture of people who could hardly understand one another. Beside, the change from working within a single culture-based homogeneous group to using a heterogeneous cross-cultural approach, I find that in music therapy I focus more and more on individual treatment.

From experience I have learned that, especially in a group, direct attention to the sustained traumas could cause very much anxiety, resistance, and avoidance . In individual music therapy I find more possibilities to offer the client a safe environment to express feelings related to a trauma and to tune in to specific and culture-related needs of the client.

In music therapy I focus on dealing with the client's own situation, and trying to process his or her own problems via nonverbal means of expression of feelings. It is noticeable that traumatized refugees often are able to sing about their misery, but find it much harder to talk about it. The instrumental music accompanying verbal improvisation (talking and singing), when closely related to the moods and needs of the client, seems to form a safe and inviting platform to express feelings. Because there is accompanying music, silences in singing become less tense, and intense emotional outbursts seem to be part of the music. The client feels supported by the music, which supports the mood he or she is in, and new phrases seem to flow freely and automatically (this is illustrated in a musical fragment from VPRO-Radio See Appendix).

Music therapy has been part of the treatment program of Phoenix and its main goals have been:

• Providing people with the means of emotional expression of feelings such as homesickness, loneliness, despair, and so forth;
• Keeping and developing people's cultural identity and their orientation according to the culture of their native country. Listening to and playing the music of their own country stimulates the experience of their culture. Especially in a process of adapting to the new culture, it is important for them to remain in touch with their own cultures. One could say that culture shows the limits of what is or is not allowed or possible; culture gives people something to hold on to. Music, as a means of expression, in many ways gives shape to culture and thus provides the patient with a certain cultural security;
• Offering musical structure as safe limits within which a client can express him- or herself;
• Stimulating social interaction; having positive experiences and enjoying things together.
• Developing positive aspects of present psychic functioning, including ego-strengthening activities aimed to stimulate initiative, to stimulate people to use their own talents, to help people influence their own (musical) environment , and to actually help the clients experience their own lives.

Four Approaches to Music Therapy

In the following paragraphs we will look at four approaches to methods of music therapy that I have often used in the past 20 years and that proved to be most suitable and successful in the treatment of seriously traumatized refugees (Orth, 2002). The main idea behind these methods is to strengthen self-determination, the ability to manage one's own affairs, and development. These methods also offer possibilities to intensively express thoughts and feelings regarding past experiences within a safe environment and then tentatively be confronted with the memories of those experiences. The methods include:

1. Compose your own relaxation music. Here the therapist supports the client in composing the client's own relaxation music.
   • Select and record your own tape/CD of music to relax by.
   • Make a live recording of your own performed music to relax by.
2. Learn how to play an instrument and play together to get in contact with feelings and expression of feelings in a safe way.
3. Making your own musical product.
4. Express your thoughts and feelings through improvisation.

Compose your own relaxation music-- Select and Record Your Own Tape/CD

Y., a refugee from Syria, used to work in his home country as supervisor of the irrigation pumps on a large estate. Because one of the pumps overheated, broke down, and caused a fire, he was heavily punished and tortured. After this incident he managed to escape and flee to the Netherlands. He now suffers from severe insomnia. Together we made a tape with the sounds of running water. If he can listen to this tape before going to bed, he relaxes and gets to sleep.

Clients often say that certain music evokes pleasant memories, that they can dream about and that the music comforts them when they feel lonely. The client can take the tape/CD with the selected music pieces home and play the music when he or she feels tense or cannot get to sleep and it has a positive influence on his or her mood. The client's ability for self-control is enhanced when he or she can modify his or her own thoughts and moods.

Another possibility is to record "live" music played by the client or group of clients with the available instruments. I will describe this option in the next paragraph. For the first possibility - select and record your own tape/CD of personally relaxing music - we mostly use music the client provides. First we listen to the different fragments of music together. Then we record the parts the client finds most relaxing which he or she could play when tension rises or when he or she worries too much. The most suitable music for this purpose is standard instrumental, predictable, of slow pace, and with an even rhythm. The selected music parts are often existing pieces, familiar to the client, pleasant to his or her ear, and evoking positive associations. Initially, the client has to pinpoint what he or she is looking for. There is plenty of ethnic music available on the Internet for this selection. The process of selecting this music by the client must focus on his or her actual situation and enhance the feeling that he or she is in control of his or her own destiny, mood, and well-being. It is desirable for the client to be asked to provide, as much as possible, his or her own music or selection, because it is hard to judge from one cultural background how other cultures appreciate and experience certain music. Feelings of sadness, happiness, and other associations that music might produce can vary greatly in different cultures (Orth, 1992).

Another advantage in bringing your own music is that by talking about this music one can make connections with the client's background and home country. Memories and feelings are often coupled while listening to a certain music piece and will give it special meaning. Some refugees might have packed their favorite CD or tape before leaving. This music can be very important as a link to certain situations or people back home. Sometimes clients have to be reminded that they have got this music. This music is often not suitable for relaxation, but can be used as an association to talk about memories of home. As a variation on the above, the therapist or the client can combine the recording with a personal story, memory, or fantasy. It is advantageous to first make a list of the client's pleasant situations, like walking along the beach, in the woods, listening to the sounds of birds, or the surf, and so forth. The music has to be renewed regularly during treatment, when the needs of the client change.

Compose your own Relaxatin Music -- Live Recording of Your Own Performed Music

Creating your own relaxation music by means of improvisation offers an attractive and pleasant therapy. This method can be used for individuals as well as for groups. It is introduced by a warm-up to get rid of dominating thoughts and to get closer to the client's own feelings. For warming up in a session we usually play a set score with a closed structure and set rhythm. Slowly we try to diverge from the score and the set rhythm and experiment with songs with more feelings. After the warm-up the clients choose sounds and instruments that evoke pleasant feelings or relaxing associations. We use various acoustic instruments, like xylophones and harps, which are tuned in pentatonic scales. These pentatonic scales have proven to be very useful because they are easy to improvise and clients from other cultures like to work with them. Rainmakers, ocean drum, and small rhythm instruments, like rhythm-eggs, are also very useful for this purpose.

One of the group members is appointed as the director/composer who decides who plays what instrument. The director also determines the tempo and the dynamics. Once the improvisation has started, the therapist accompanies the group by playing recurring chord schemes on the piano or the guitar. The accompaniment functions only as a supporting structure to simplify the improvisation and to produce a certain atmosphere, by playing minor or major keys and different rhythms. The director conducts.

It is a special sensation to witness how people from different countries, having trouble to verbally communicate and often being self-occupied, all start playing together in a very short time. People are watching one another; they are focused on playing together. Language is no longer a barrier.

The experience of being able to influence one's own mood by making one's own relaxation music, often recorded for use in the ward, is a valuable contribution to the health of the traumatized clients in general. It is of even more value to the director, who becomes aware of the influence he or she has on fellow group members. It is the momentary relief of the hustle and bustle of thoughts, getting the chance to be involved with the things happening around them, that leads to relaxation and creates the circumstances needed to be able to deal with trauma. This strengthens the clients and provides them with the means to focus on the future. Apart from these ego strengthening activities and the group experience, this program provides ways for emotional expression and experiencing one's own cultural identity.

Learn How to Play an Instrument and Play Together

Many clients expect to learn how to play an instrument during music therapy. Although this is normally not the intention, it can happen when it offers a possibility to get out of a state of anxiety and create a mode for expression, structured by playing music together. I often use drumming for this purpose. Because many clients, especially in the beginning of therapy, find it hard to cope with loud sounds, we sometimes use ear protectors. Drumming is both a difficult technical and physical effort with hands and feet acting independently and it requires some ability to keep a rhythm. It demands concentration and targeted exertion, and it hardly leaves room for other thoughts or engagements that control the tension experienced by these clients. The traumatized clients seem to accept and express their feelings through the music better after they get rid of their dominating thoughts and anxiety. Accepting and expressing their own feelings is something many traumatized clients find difficult. To play music together and to communicate intuitively is essential to experience contact with others.

A. is an 18-year-old ex-child soldier from Sierra Leone with PTSD. A. suffers from reliving experiences, nightmares, chaos in his head, anxiety and panic disorder, and he fears loss of control and tension. He isolates himself from the other clients and worries a lot. In music therapy I try to break through his social isolation and offer him means to express himself in a controlled and safe way. Because of his interest in pop music, I teach him to drum a basic pop rhythm. In two sessions A. manages to play this rhythm. Concentrating for 15 to 20 minutes on the drums seems to give him a relaxing feeling and he indicates that he does not feel any anxiety when playing. But he plays rather like a robot and not always at the same pace. This changes when I accompany him with chords on my electric guitar in his rhythm and so find the connection. When I play more dominatingly, A. changes from playing as an individual to playing more as a unit. He manages to drum with more fluidity and rhythm. Afterwards we experiment with changes of pace and dynamics when I play faster, slower, harder, or softer. A. adjusts easily to these changes. In order to do that he has to diverge from his fixed pattern and trust his own feelings for rhythm. A. obviously enjoys this experience and his drumming becomes even more meaningful when we start to practice solos and include improvisations. In five consecuetive sessions I challenge A. to follow me in playing faster, louder, and more briskly, but also adjust his playing when I play slower or pianissimo.

His own ability to drum the basic pop rhythm and my stabilizing influence as a guitar player on his performance, formed for A. a safe foundation to fully surrender to the music and to experiment safely with the expressions of his feelings. He beats out his frustrations on the drum set. With me playing the guitar, cajoling, challenging, and supporting, A. seemed to find this an agreeable, controlled way to release pressure and to cope with feelings of inability and frustrations. In drumming, his behavior is a reflection of his self-expressive needs. The adaptability of music provides many avenues for self expression in performing and listening; they run from simple and random to complex and highly organized. Such a wide range also offers many socially acceptable ways of expressing negative feelings, energetic behavior, or closeness, any of which can reduce the need for expression in more overt, unacceptable forms. The movement from random expression to organized, meaningful expression is the goal. In this case the musical activity provided a range of emotional expressions, expressions not otherwise permitted were acceptable in music.

Making Your Own Musical Product

Recording one's own story on tape or CD can be an inviting way to tell one's story and deal with it. The tape or CD is a personal product a client can let other people listen to, can hide away, or keep for him- or herself only. It is suitable especially towards the end of the treatment. Sometimes we compile a tape of the previously made tapes. Sometimes we play "live" music or use music that is essential to the story of the client, and the client then tells, raps, or sings to it.

Before the recording the client writes down his or her story (e.g., about the client's escape or the treatment process). The client sings or tells this story and the therapist frames it with suitable music chosen by the client. This music can be performed by the therapist or together with the client or it can be prerecorded music. As music often evokes certain feelings, or because music expresses exactly someone's feelings, the client, especially now, should select music that matches the story. In this method there is little or no improvisation; the story and the order of the story are mainly predetermined as well as the practical means to express the story. Many clients utilize symbolic images for their stories.

L. is a 35-year old woman who fled from Iran when her husband was arrested and tortured because of political activities. L. tells in the "song" about a beautiful singing bird, which is threatened and maltreated in her environment, and then escapes. The bird can no longer fly because of the maltreatment and has to recover in a safe place. There it licks its wounds and becomes stronger again so that it is able to return. Between the lines L. tells us about her setbacks in the process of her own recovery and she thanks the people who have helped her.

Making a tape or CD such as this one can be a way to evaluate and support the final stages and completion of the treatment.

Controlled Expression of Thoughts and Feelings through Improvisation

In musical improvisation someone can express him- or herself directly. Norms and perfectionism can be relaxed or ignored and a "mistake" does not impede the self-awareness, but can be used as a spontaneous occurrence and offer new possibilities. We use the effect that music has to enhance verbal and nonverbal social interaction and communication. It is easier to talk with music in the background, and gaps in the talking or singing are no longer threatening. Clients can express through music feelings otherwise not expressible. The therapist's playing and his or her constant presence create a safe foundation where the client can experiment and improvise and be continually involved with his or her surroundings. An awareness of others and the relation to them are constantly required to feel at ease and supported in the process of achieving a musical expression and interpretation.

In the method of "controlled expression of thoughts and feelings through improvisation," the therapist, together with the client, looks for "live" music that is similar to the mood of the client at that moment. This can easily be achieved by using a keyboard or guitar as base instrument. I usually first experiment with the pace, then with the key, and finally with the musical styles and chord pattern. It is advisable to keep searching and ask for the clients' preference, until it is pleasing enough and he or she is able to present and express his or her thoughts. When the desired chord pattern, pace, and style have been found, the "live music" can be used as a foundation for the vocal improvisation. The chords pattern in a fitting key is played continuously. If there is an amplifying system, the client could use a microphone and by using the sound effects on the sound system, change the mood of the voice to his or her needs. It is also easy to make a sound recording. The client is asked to speak or sing texts or thoughts that come to mind. In my experience this is reasonably easily done and there is hardly any hesitance. It is striking to notice that when the client sings, it is seldom out of tune or in a wrong rhythm. This does happen more often when the client sings existing music. The continuous repetition of the chords pattern creates a safe structure in which the client can express his or her thoughts and where he or she feels at ease and understood. In this setting it feels logical when pauses or silences appear in the story or text. In this routine the client looks for the appropriate music that converges with his or her mood and also decides whether to talk or to sing. According to Smeijsters (1989), although singing has a strong connection with a language, the text in singing is less important than in language. Speaking and writing have a function to express a thought coherently. As words themselves are symbols of certain objects, subjects, and actions, they are sufficient to communicate that statement. The text in a song is not considered sufficient in itself, but must be completed with musical information. This musical information is in many cases more important than the text. It is understandable that a text can get more meaning through the music.

For small children who do not have the power of language, sounds indeed are the only way to communicate. At the beginning these sounds are hardly distinguishable, nothing more than a shout at the moment the child wants to be fed or cleaned. Afterwards the child starts to play with this sound and so the rudiments of its future musical expressions, based on his own culture, are founded. The function of the shout is mainly instrumental. The child wants to be satisfied and shouts in order to exert power over its surroundings. In the first instance adults also shout, when they cannot cope with the situation in another way. The shout is the last means to try to control a situation. In other words, the shout is an expression of mental discord and frustration and at the same time a signal to the outside world. This shout can be cultivated with musical assistance, but it can express the same feelings. Mainly because shouting is not an accepted way of expression, people seek a sublimated expression, an expression that is acceptable (Smeijsters, 1989, p. 92).

Musical singing makes it possible to express mental frustration. Even if the music does not serve as a power source in the communication, expressing oneself in this way allows clients the feeling that they regain power over their own existence. The language in which to talk or to sing in improvisations is decided by the client. Singing or talking in his or her own mother tongue is often easier and offers more safety because the therapist cannot understand it. On the other hand, it can also be more difficult, because it is closer to the client and more direct. Most of the time the clients start off in English or French and later on they continue in their own language. Then the therapist can, most of the time, see and hear more emotions.

After the improvisation I normally ask the client what they talked or sang about and what was felt. We also discuss how to continue; are we changing the style, are we going to do instrumental improvisation or just listening? What is important is that the client, after the improvisation, can handle what he or she released or what (maybe against his or her prior intention) has been expressed. For this reason we have to agree beforehand how to deal with these fierce emotional feelings or whether it is essential to have a good ending to the session, where the music therapist could offer a relaxing routine.

Recurring thoughts from dreams or sleepless nights could also be used as a subject for an improvisation. The client can be asked to note these thoughts when he or she cannot sleep or when jolted awake after a dream. This approach is used regularly, since it helps the client to sleep at night and to deal with thoughts and problems during the day. Certain themes for the improvisation return regularly. For sake of variation only the music can be altered, while the key words or the theme stay almost the same (e.g., a bluesy text is used as a base, but the music is changed into a rock and roll or rap style). Using this variation a heavy theme could still sound optimistic. On the other hand, it is also possible to stay with a trusted style of music and just change the text.

An Example Using Combined Methods

By way of example I give an account of music therapy with S., in which a combination of different strategies was used (Drogendijk, 2000):

S. is a 21 year young man from Liberia. After many traumatic events he managed to escape to the Netherlands. In his home country he was a child soldier. The military kidnapped him when he was 12 years old. His mother was killed before his eyes, when she attempted to keep him safe from the claws of the army. The rest of the family were probably murdered too. As a child soldier he was forced to do many activities, including sexual activities. In the war he had to fight and he killed a number of people under the influence of drugs. He had to kill his "blood brother" when he got wounded during a fight and he did not want him captured by the opponents. During the fighting he himself was also wounded. Two years before his admission to the Phoenix clinic he escaped to the Netherlands. He befriended a Dutch woman and they got a daughter. The day before they intended to get married, the authorities cancelled the marriage. At the moment of his admission he still had not received his definite residence permit.

At the beginning of his treatment S. could not cope with his tension. He expressed this tension by hitting the trees outside with sticks. He also had been suffering from insomnia because he was tortured by nightmares of such magnitude that he was afraid to go to sleep. S. (maybe under pressure from his lady friend) was pushing himself to get better as soon as possible. He was often negative about the future and said that he was worthless and could not do anything. This resulted in his determination to start therapy. At the beginning of the music therapy treatment of S., the functions and goals were:

• trying to control the tensions;
• being able to handle the traumatic memories and the emotions they produced;
• developing a feeling of control over his own life;
• gaining confidence by learning different forms of music.

During the first sessions he was asked what he wanted to do in music therapy and said that he wanted to learn how to make music. S. proved to be a very motivated client. He finished his tasks with great accuracy, and was eager to learn. S. was a perfectionist. When he did not succeed in some tasks he got angry and concluded that he could not do anything; he was unable to take his special situation into account.

Control the Tensions

At certain moments tension was rising. During the therapy S. seated himself at the piano and hit the keys in an a-rhythmic fashion, without melody or theme. I went to the drumset and started to play the drums. First I played as fast as he played, but then I started to play slower and with more controll S. was forced to adjust his playing to mine and had to play slower. Because I offered him a structure, I could influence the way S. responded. The musical structure formed a safe foundation on which he could let go. S. also took drumming lessons that offered an additional opportunity to play in a very structured way.

Handling the Traumatic Memories and the Emotions They Produce

I asked S. to write down everything that worried and/or kept him awake at night. S. made two texts, the first concerning his situation in the Netherlands and a second where he narrated in short the history of his country. In this text he also briefly described his own experiences. In the beginning S. did not want to sing in the African music style he usually used to improvise on; probably because the frightening memories were rising faster through sensorial perception. We therefore decided to start singing western pop music. On one occasion when he was singing the text about his home country in a minor key, he suddenly left the room, because the tension was too much. He returned to the ward screaming. He found it difficult to sing because he believed he could not sing properly. During the following weeks we altered the texts and he then practiced the singing itself.

Making song texts is an effective way to structure the thoughts of traumatic experiences (Orth & Verburgt, 1998). Rewriting older texts and making new texts result in less tension than before. After three months, twice a week music therapy, we reached a break through. A psychology student who did her fieldwork in the clinic followed the music therapy sessions with S. Together, we prepared ourselves as usual: we tuned the instruments and got the installation ready. With just the two of us playing African-sounding music, S. walked in. He took position behind the microphone and improvised on the music. It seems that the words fell into place and the melody came naturally. He talked about the things that happened in his life as a young soldier and about the death of his family. At that moment he fully surrendered, probably too far, because after a while the tension had risen too high and he walked out. During the following sessions, I had the feeling that he wanted to see how far he could go with the recollection of his memories. In order to give more structure to his improvisations, he started to write song texts again. At the end he eventually sang these texts accompanied by African music, and he could handle the tension better when talking about his experiences.

Developing a Feeling That You Can Manage Your Own Life

S. could indicate what he wanted to do and how far he wanted to go in the therapy sessions. In making songs he was in charge. After a difficult session he chose to leave or talk about his feelings. Sometimes, when he requested this, we listened to relaxing music. Having the client decide for him- or herself can reduce feelings of inability.

Gaining confidence by learning different forms of music

Most of the time we recorded the music. S. was proud to let fellow participants and nurses hear these recorded music fragments in the living room. His ability to drum gave him a lot of confidence. Because S., besides telling his story through the music, could also express the feelings linked to it, it aided him in coping with the traumatic experiences. Making a recording and listening to it made it possible to deal with the traumas in a more distant manner. S. could express himself easier, because the music invited him to do so and gave him a structure. He was able to focus his thoughts at a moment he selected himself during the day, and as a result he could sleep better at night.

Conclusion

Methods of music therapy in trauma treatment that have already been developed, have some limits in working with traumatized refugees. Differences in language, (musical) culture and the fact that most refugees still deal with stress inducing aspects caused by their present situation, ask for an adaptation of these methods with special attention to social and cultural aspects, in order to be useful for traumatized refugees. Group music therapy for traumatized refugees may be useful because of the common themes and complaints refugees share, but in my experience, especially in the beginning, it is very difficult to offer sufficient safety. Confrontation with loud sounds, vivid interaction of other group members and differences in (musical) culture can make these clients fearful and avoiding. But activities focused on reducing actual complaints and distraction from dominating thoughts, such as "making one's own relaxation music" are experienced as pleasant. To attain more results with regard to a trauma, it is my preference to offer individual music therapy. An individual approach makes it possible to pay special attention to specific cultural needs, more safety and intensity.

Over the past years, the described methods of working with traumatised refugees, have fully taken shape. Apparently, any one such method, or a combination, is nearly always applicable. The road is open for building further experience and research.

It is my hope that the above article will give an impetus to further development of methodology, based on experience and (empirical) research.

Notes

[1] This article is based on my contribution to the chapter "Sounds of trauma" in "Broken Spirits: The treatment of asylum seekers and refugees with PTSD" (Wilson & Drozdek, 2004).

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Appendix

This audio excerpt is taken from a public Dutch radio documentary [Music Therapy with Traumatised Refugees] by VPRO-radio , broadcasted in two parts on January 12 and January 19, 1999. The reporter of the program is Michael Janssen. Further below is also an english translation of the comments on the audio fragment. The excerpts is published here with the kind permission from VPRO and Michael Janssen

Radio fragment:Windows Media Audio-file (1,91MB)/MP3 Audio-file (2,62MB) ]

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Translated Comments

[What you hear is no popsinger with some exotic name. Neither do you listen to the rehearsal of a 'world music'- artist. What you hear is a fragment of therapy with a former government army sergeant of an African dictatorial regime. No music for having fun or for doing a bit of dancing, - not, at least, for the time being.

This is music to set things straight. Music to bring clarity to the immense confusion in the head of this soldier. A head that was confronted for years on end, with killing and being killed. A head for which no other option remained, but to flee. Away from the place, where a human life is not worth a penny. Away from the civil war that demands of you, that you are witness of the slaughtering of your own family. An eye for an eye, a tooth for a tooth.

Away, with the only plane that is leaving, and which is supposed to contain your wife and two children also. And what else can you do, than turn mad, when they appear not to be there. When later on messages come in, that no one has seen them, and the prospects are getting ever dimmer.

This former sergeant is now one of those who walk around with wavering pace and bent shoulders, because of psychiatric medication. Apparently, because it cannot be otherwise. Someone, who falls silent when he is asked to talk about the horrors in his life, but who is less inhibited when he can sing his story.

That is the reason, that Jaap Orth works with music fitting to this man's culture. Music, that for this man is familiar and with which he can identify.]