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   <front>
      <journal-meta>
         <journal-id journal-id-type="DOAJ">15041611</journal-id>
         <journal-title-group>
            <journal-title>Voices: A World Forum for Music Therapy</journal-title>
         </journal-title-group>
         <issn>1504-1611</issn>
         <publisher>
            <publisher-name>GAMUT - Grieg Academy Music Therapy Research Centre (NORCE &amp;
               University of Bergen)</publisher-name>
         </publisher>
      </journal-meta>
      <article-meta>
         <article-id pub-id-type="doi">10.15845/voices.v20i2.2891</article-id>
         <article-categories>
            <subj-group subj-group-type="heading">
               <subject>Research</subject>
            </subj-group>
         </article-categories>
         <title-group>
            <article-title>Music as the Medicine of Trauma among Refugees in Arizona</article-title>
         </title-group>
         <contrib-group>
            <contrib contrib-type="author">
               <name>
                  <surname>Muriithi</surname>
                  <given-names>Bernard Austin Kigunda</given-names>
               </name>
               <xref ref-type="aff" rid="B_Muriithi"/>
               <address>
                  <email>bernardmuriithi@atsu.edu</email>
               </address>
            </contrib>
         </contrib-group>
         <aff id="B_Muriithi"><label>1</label>A.T. Still University of Health Sciences, USA </aff>
         <contrib-group>
            <contrib contrib-type="editor">
               <name>
                  <surname>Hadley</surname>
                  <given-names>Susan</given-names>
               </name>
            </contrib>
         </contrib-group>
         <contrib-group>
            <contrib contrib-type="reviewer">
               <name>
                  <surname>Norris</surname>
                  <given-names>Marisol</given-names>
               </name>
            </contrib>
            <contrib contrib-type="reviewer">
               <name>
                  <surname>Bautista</surname>
                  <given-names>Ezekiel</given-names>
               </name>
            </contrib>
         </contrib-group>
         <pub-date pub-type="pub">
            <day>1</day>
            <month>7</month>
            <year>2020</year>
         </pub-date>
         <volume>20</volume>
         <issue>2</issue>
         <history>
            <date date-type="received">
               <day>25</day>
               <month>9</month>
               <year>2019</year>
            </date>
            <date date-type="accepted">
               <day>28</day>
               <month>4</month>
               <year>2020</year>
            </date>
         </history>
         <permissions>
            <copyright-statement>Copyright: 2020 The Author(s)</copyright-statement>
            <copyright-year>2020</copyright-year>
            <license license-type="open-access"
               xlink:href="http://creativecommons.org/licenses/by/4.0/">
               <license-p>This is an open-access article distributed under the terms of the
                     <uri>http://creativecommons.org/licenses/by/4.0/</uri>, which permits
                  unrestricted use, distribution, and reproduction in any medium, provided the
                  original work is properly cited.</license-p>
            </license>
         </permissions>
         <self-uri xlink:href="https://voices.no/index.php/voices/article/view/2869"
            >https://voices.no/index.php/voices/article/view/2869</self-uri>
         <abstract>
            <p>This paper presents outcomes of a phenomenological study conducted to explore the
               lived experience of refugee musicians. Purposive and snowball sampling methods were
               used to identify six musicians who performed in the cities of Phoenix and Tucson and
               had been involved in music prior to entering the United States. The primary data
               gathering method was structured and unstructured interviews, but observations were
               made for the musicians who performed in public events during the study period. Audio
               and video recordings were made and photographs taken during these performances. Study
               outcomes show that the musicians have persisted in music performance as their primary
               method of healing trauma and negative emotions. Traumatic experience resulted in
               their fleeing from their homes and seeking refuge in other countries. After being
               resettled in the United States, they continue to suffer from the experience of loss,
               need to adapt and change, and struggle with trauma and negative emotions. Music is
               their method of healing trauma and facilitating integration. Music produces healing
               through 1) like a painkiller, enabling them to forget problems that result in
               distress, 2) being their means to communicate a message of hope, and 3) enabling
               integration, thus reducing isolation and loneliness.</p>
         </abstract>
         <kwd-group kwd-group-type="author-generated">
            <kwd>African immigrants</kwd>
            <kwd>healing</kwd>
            <kwd>forced displacement</kwd>
            <kwd>community integration</kwd>
            <kwd>community music therapy</kwd>
         </kwd-group>
      </article-meta>
   </front>
   <body>
      <!-- sec lvl 2 begin -->
      <sec>
         <title>Introduction</title>
         <p>According to the United Nations Refugee Agency, 70.8 million people were forcibly displaced worldwide in 2018
               (<xref ref-type="bibr" rid="UNHCR2019">United Nations High Commissioner for
               Refugees [UNHCR], 2019</xref>). Of those, 25.9 million were refugees, 41.3 million
            were internally displaced, and 3.5 million were asylum seekers (<xref ref-type="bibr"
               rid="UNHCR2019">UNHCR, 2019</xref>). In 2017, 80,000 refugees and asylum seekers,
            mostly from the Democratic Republic of Congo, Iraq, and Syria, were admitted to the
            United States (US) (<xref ref-type="bibr" rid="UNHCR2019">UNHCR, 2019</xref>).
            Generally, survivors of forced displacement have a history of emotional turmoil or
            trauma because they witnessed serious atrocities, such as murder, rape, and torture. As
            such, refugees and asylum seekers continue to be affected psychologically in their host
            countries. In a study of refugee students in North Korea, Choi (<xref ref-type="bibr"
               rid="C2010">2010</xref>) found avoidance, disgust, loneliness, feelings of loss,
            and fear were common despite treatment with music therapy. Several studies (<xref
               ref-type="bibr" rid="D2009">Davies, 2009</xref>; <xref ref-type="bibr" rid="SMM2019"
               >Saksena &amp; McMorrow, 2019</xref>; <xref ref-type="bibr" rid="SGDGGD2016"
               >Shishehgar et al., 2016</xref>) have identified barriers to successful resettlement,
            including lack of language competence resulting in isolation, limited work and leisure
            activity due to language and financial challenges, difficulty maintaining habits and
            routines due to unfamiliarity with the environment, loss of family for practical and
            emotional support, loss of social connectedness because of differences between the
            country of origin and the host country, and culture shock.</p>
         <p>Although it is widely acknowledged that refugees need access to mental health services
               (<xref ref-type="bibr" rid="H2018">Hynie, 2018</xref>), most resettlement policies do
            not prioritize the health, education, and social wellbeing of refugees (<xref
               ref-type="bibr" rid="BW2018">Burbage &amp; Walker, 2018</xref>). This lack of access
            may be related to low prioritization of mental health in federal and state policies and
            to the high cost of healthcare in the United States (<xref ref-type="bibr" rid="PJ2018"
               >Papanicolas et al., 2018</xref>). The failure to address mental health symptoms
            among refugees can in turn affect quality of life and productivity of these
            individuals.</p>
         <p>The use of music when serving the mental health needs of refugees has had reported value
            in refugee camps (<xref ref-type="bibr" rid="A2001">Akombo, 2001</xref>; <xref
               ref-type="bibr" rid="DS2007">Dau &amp; Sweeney 2007</xref>), for individuals with
            sleep disturbances (<xref ref-type="bibr" rid="JV2012">Jespersen &amp; Vuust,
               2012</xref>), and in community (<xref ref-type="bibr" rid="F2013">Felsenstein,
               2013</xref>; <xref ref-type="bibr" rid="SB2006">Signorelli &amp; Bright, 2006</xref>)
            and clinical settings (<xref ref-type="bibr" rid="C2010">Choi, 2010</xref>; <xref
               ref-type="bibr" rid="JV2012">Jespersen &amp; Vuust, 2012</xref>; <xref
               ref-type="bibr" rid="J2016">Jin, 2016</xref>; <xref ref-type="bibr" rid="O2005">Orth,
               2005</xref>). Research has also shown the effectiveness of music in dealing with
            posttraumatic stress disorder among refugees (<xref ref-type="bibr" rid="BLSSTCLM2018"
               >Beck et al., 2018</xref>; <xref ref-type="bibr" rid="F2013">Felsenstein,
            2013</xref>). In one study, the inclusion of refugees in a Swedish choral music
            performance helped them integrate into their new communities, but more appropriate
            models of applying music for this purpose are indicated (<xref ref-type="bibr"
               rid="QV2017">Quadros &amp; Vu, 2017</xref>). In another report, music therapy aided
            intercultural exchange and provided opportunities for integration through singing and
            performing percussive music (<xref ref-type="bibr" rid="PA2016">Posselt &amp; Antink,
               2016</xref>). Despite the cultural (and musical) differences between musicians with
            refugee and Unites States backgrounds, the readiness and ability to engage both in
            shared music making activity has value in the overall health and integration of these
            individuals into a community. </p>
         <p>Evidence also suggests that refugees could apply music and dance to manage their own
            stress and deal with trauma. The 2007 award-winning documentary <italic>God Grew Tired
               of Us</italic> shows how the Lost Boys of Sudan experienced deep emotional wounds and
            trauma after the death of their parents and escape to the Kakuma refugee camp in Kenya
               (<xref ref-type="bibr" rid="DS2007">Dau &amp; Sweeney, 2007</xref>). Despite the
            horrific situation, they still experienced moments of relaxation at the refugee camp
            because music performance and dance helped them, for a moment, to forget their trauma
            and sense of despair. These musical experiences are not strictly music therapy as
            defined in the West, and there are ongoing discussions about suitable terminologies for
            this ontological reality. Stige (<xref ref-type="bibr" rid="S2002">2002</xref>)
            proposed “folk music therapy” whereas Kigunda (<xref ref-type="bibr" rid="K2003"
               >2003</xref>) described similar practices as “some form of music therapy” which could
            benefit from premeditated processing and refinement to (metaphorically) become “canned
            music therapy” (<xref ref-type="bibr" rid="K2004">Kigunda, 2004</xref>). Music was not
            the only factor supporting the Lost Boys of Sudan, but it helped change despair into
            hope in this vulnerable population. The therapeutic impact of music here is similar to
            that of professional music therapy. As such, music therapists and other clinicians can
            learn much from studying how refugees use music to address trauma. This can only improve
            the approaches used to address refugee health and wellness.</p>
         <p>As music therapists and other professionals advance research into clinical approaches
            that may provide refugees necessary relief from mental health problems, there is value
            in understanding the shared and individual experiences of refugees as a means of
            determining possible solutions. One way to approach this problem is to find out how
            refugees already use music in their lives. Thus, by understanding their lived experience
            in relation to the daily application of music, their health-related issues and other
            challenges can be better addressed. Although experimental studies provide important
            evidence for approaches that serve the needs of refugees and are generalizable to other
            populations, qualitative research studies are necessary to characterize experiences that
            are multidimensional, complex, subjective, immeasurable, and more nuanced. Researchers
            investigating the application of music in healing require a better awareness of the
            realities that change between peoples, contexts, times, and cultures. Further,
            understanding the lived experience of refugees allows music therapists and other
            professionals to develop needed assessment methods and treatments. For instance, better
            assessment tools are needed that consider cross-cultural understanding of posttraumatic
            stress disorder and other mental health problems affecting refugees (<xref
               ref-type="bibr" rid="ERKCR2018">Eklund et al., 2018</xref>; <xref ref-type="bibr"
               rid="GMFN2017">Gadeberg et al., 2017</xref>). Approaches to treatment must also be
            informed by the refugee’s view of the world and concept of healing. The utility of
            music, in particular, must be directed by their understanding of music and how it
            supports recovery from trauma, anxiety, and depression. Most importantly, we should be
            aware that what refugees need may not necessarily be found in the theories and
            approaches designed for Western clients.</p>
         <p>The aim of the current study was to determine how music performance produces
            health-related benefits perceived as therapeutic and supportive of health, growth, and
            wellness of refugees, their families, and communities. To gain an in-depth understanding
            of the lived experiences of refugee musicians, a phenomenological design was used. This
            design allows the voices of refugees to be clearly understood as they report what
            matters to them in a richly engaging manner. As a result, music therapists, other
            professionals, and persons living in host countries can be better informed to create
            models that facilitate the use of music and talent for the benefit of the refugees and
            the communities in which they are resettled. </p>
      </sec>
      <!-- sec lvl 2 end -->
      <!-- sec lvl 2 begin -->
      <sec>
         <title>Methods</title>
         <!-- sec lvl 3 begin -->
         <sec>
            <title>Phenomenological Design</title>
            <p>The current study used a phenomenological design because the phenomenon under
               investigation had objective and subjective elements that required methodological
               flexibility. Phenomenology allows for mixing of methods, triangulation of different
               kinds and sources of data, and descriptive and interpretive approaches. Thus, the
               researcher can examine the phenomenon from the point of view of participants while
               collecting a variety of data for analysis. Phenomenology is a strong approach to
               understand the human experience without the limitations of objective or subjective
               methods. </p>
            <p>Phenomenology begins with epoche, also called bracketing, where the phenomenon is
               considered without bias (<xref ref-type="bibr" rid="G2012">Gallagher, 2012</xref>;
                  <xref ref-type="bibr" rid="K2012">Kigunda, 2012</xref>). The next step is
               phenomenological reduction, where the time and context of the phenomenon is
               considered with an awareness that the participants’ lived experience may change with
               changes in context or environment. Finally, eidetic reduction is used to imagine all
               possible variations of the phenomenon without changing the essence of the phenomenon
               under examination (<xref ref-type="bibr" rid="G2012">Gallagher, 2012</xref>). This
               process enables researchers to narrow down a phenomenon to what is essential to an
               experience or phenomenon (<xref ref-type="bibr" rid="G2012">Gallagher, 2012</xref>;
                  <xref ref-type="bibr" rid="K2012">Kigunda, 2012</xref>).</p>
         </sec>
         <!-- sec lvl 3 end -->
         <!-- sec lvl 3 begin -->
         <sec>
            <title>Participants</title>
            <p>The current study used purposive and snowball sampling to identify six study
               participants. Initial contact was made when the researcher met refugee musicians at
               community events, such as World Refugee Day celebrations in 2018 and 2019 and World
               Bazaar PHX in 2019, where refugees from around the world perform to entertain guests.
               Other contacts were obtained through refugee resettlement agencies. Those invited to
               participate in the study were artists involved in music making before and after being
               resettled in the US. The number of years that participants had been in the United
               States ranged from one year to over 10 years, and all were admitted to the United
               States as refugees. Participants worked in other industries and did not primarily
               make music to earn their living, but they all verbalized that as an unfulfilled
               desire. Four of the selected musicians (Furaha, Baraka, DJ Grin, and MC Joel) were
               originally from the Democratic Republic of Congo (DRC) and lived as refugees in
               Uganda before being resettled in the US. Two of these Congolese musicians (Furaha and
               Baraka) were from the same family and included a mother and one of her adult sons who
               often performed and recorded music as a family. One of the remaining participants was
               originally from Burundi (Don Brighter) and was a refugee in Tanzania before being
               resettled in the US. The last participant was from the Kachin tribe (Zau), and he had
               started making music in Myanmar before being resettled in the United States with his
               family. Only participants who could communicate in English or Kiswahili were included
               in the study although other participants were considered if an interpreter could be
               found.</p>
         </sec>
         <!-- sec lvl 3 end -->
         <!-- sec lvl 3 begin -->
         <sec>
            <title>Data Collection </title>
            <p>After participants were identified, the aims of the study and the roles of
               participants were explained to them, when necessary with interpretation into
               Kiswahili. The consent forms described the study and their role in detail, including
               the need to commit to at least 75 minutes of an initial face-to-face interview
               (structured and unstructured) and subsequent phone interviews or conversations as
               needed to clarify any unclear statements. Participants additionally consented to
               observation, photographs, and video recordings whenever they performed music in the
               community. All but one of the participants provided links to their YouTube channels.
               Although this medium included valuable video material for analysis, it was not
               required for participation in the study. None of the participants was concerned about
               privacy. Instead, they preferred to be identified by their own stage names and saw
               their participation in the study as part of being recognized as musicians. They also
               considered the extra exposure would be beneficial for their musical careers and
               increase their popularity. They were lastly asked to sign Institutional Review
               Board-approved consent forms.</p>
         </sec>
         <!-- sec lvl 3 end -->
         <!-- sec lvl 3 begin -->
         <sec>
            <title>Structured and Unstructured Interviews</title>
            <p>The primary method of gathering data was structured and unstructured interviews. The
               following five guiding questions were considered when preparing the interview
               questions: (a) Did participants perceive that music performance contributed to their
               subjective wellbeing and to the wellbeing of their families and communities? Why or
               why not? (b) What function(s) did music serve (or was perceived to serve) in the
               health and wellness of participants, their families, and communities? (c) What
               environmental barriers to their music making did the participants encounter? (d) What
               steps had participants taken to mitigate the impact of perceived barriers in their
               performance? and (e) What did participants perceive as possible solutions to the
               challenges they faced regarding their music performance? From these, the primary
               investigator created a questionnaire of 13 open-ended questions that was used in all
               structured interviews. If issues arose from these initial questions, follow-up
               questions were used to clarify answers. </p>
            <p>At the end of the structured interview, participants were asked to provide any other
               details about their experiences that they thought were pertinent for the current
               study. As a result, unstructured interviews immediately followed the structured
               interview. The unstructured interviews were flexible, and their content varied
               depending on what the primary investigator (interviewer) and participant wanted
               clarified. The primary investigator is proficient in Kiswahili and translated some of
               the questions from English to Kiswahili during interviews to ensure that participants
               with limited English proficiency were understood. Notes were taken during interviews,
               and all structured and unstructured interviews were audio recorded. The interviews
               were transcribed verbatim and used in subsequent analyses.</p>
         </sec>
         <!-- sec lvl 3 end -->
         <!-- sec lvl 3 begin -->
         <sec>
            <title>YouTube Channels</title>
            <p>Five of the six participants had YouTube channels where they posted their music and
               had followers. They provided links to these channels on the initial interview day and
               continued to post new videos during the study period. The collection of older and
               newer music videos on these channels provided data to assess changes in their music
               performance over time.</p>
         </sec>
         <!-- sec lvl 3 end -->
         <!-- sec lvl 3 begin -->
         <sec>
            <title>Observations</title>
            <p>Some of the participants were invited performers at events organized collaboratively
               by state and non-governmental organizations. Participating agencies include Arizona
               Refugee Resettlement, Catholic Charities, International Rescue Committee, Lutheran
               Social Services and a number of other smaller agencies. The participants were
               generous in communicating whenever these events were scheduled, and they were invited
               as music performers. The investigator attended many of these events, made video
               recordings, and took photographs. Some of the events were World Refugee Day 2019,
               World Bazaar PHX, and Phoenix Unknown to name a few.</p>
         </sec>
         <!-- sec lvl 3 end -->
         <!-- sec lvl 3 begin -->
         <sec>
            <title>Analysis</title>
            <p>To increase reliability and objectivity, triangulation was used when analyzing the
               interviews, video and audio recordings, and observations so that the resulting themes
               would characterize the lived experience of music performance and healing for the
               study participants. The information conveyed by participants during the separate
               interviews was compared for similarities and differences. Those themes were then
               compared with the themes from the text of songs obtained from studio recordings and
               live community performances. Essential overall themes were obtained through this
               process.</p>
            <p>It should be noted that the study investigator was instrumental in planning,
               gathering, analyzing, and presenting the data. While the goal for the study was to
               describe the lived experiences of the participants, the investigator determined what
               to include, the organization of the content, and the degree of in-depth description.
               Another consideration when interpreting study results is that the phenomenological
               approach relied heavily on the ability of the investigator to correctly and
               adequately describe, interpret, classify, and present essential elements of the
               study. For instance, a different investigator may have interpreted the data
               differently, selected different areas of focus, or presented the results in a
               different way. The investigator sought to ensure that the study focus was on the
               views shared by participants and not on interpretations of the investigator. </p>
         </sec>
         <!-- sec lvl 3 end -->
      </sec>
      <!-- sec lvl 2 end -->
      <!-- sec lvl 2 begin -->
      <sec>
         <title>Results and Discussion</title>
         <!-- sec lvl 3 begin -->
         <sec>
            <title>Background Considerations</title>
            <p>Without careful consideration of individual life stories, only limited understanding
               of the lived experience of study participants is possible. However, full accounts of
               the participants’ life stories are outside the scope of the current article.
               Therefore, selected facts are presented for better comprehension of study results.
               Understandably, all participants had an acute, deeply entrenched awareness of their
               personal backgrounds because of the traumatic experiences that led them to flee their
               home countries, leaving behind property and loved ones. The refugee camps in which
               they lived afterwards, both in countries near their home countries and in the US,
               presented different kinds of challenges to overall living and to music performance. </p>
            <p>Furaha is the mother of eight children. In the DRC, she led her church choir,
               performed music during church services, and recorded gospel songs. She escaped to
               Uganda with her children after witnessing murders and rape in her country. Once in
               Uganda, she adapted to the Kampala environment and continued to perform gospel music
               for the new urban audience. She recorded music with her children, produced videos for
               sale, and was a dressmaker to supplement her income. She was eventually resettled in
               the United States with all her children, where she continues to make music, produce
               videos, and perform at community events (Figure 1). She reported that her music was
               much more appreciated in the DRC and Uganda. She attributed the lack of comparable
               interest in her (gospel) music in the United States to a general lack of interest in
               music among United States’ residents, although this is disputable if expressed this
               way.</p>
            <fig id="fig1">
               <label>Figure 1</label>
               <caption>
                  <p>Furaha (right) and her family and friends performing Igwe at a church concert
                     in Phoenix (Furaha Nsimire.F, n.d.). There is a studio-recorded version of Igwe
                     (recorded in Kampala, Uganda) posted in another of her YouTube channels (Furaha
                     Nsimire, n.d.).</p>
               </caption>
               <graphic id="graphic1"
                  xlink:href="Pictures/1000000000000F000000043826002D346A7E8BB9.png"/>
            </fig>
            <p>Furaha’s son Baraka began performing music in Kampala, Uganda. Because the family
               lacked basic things, he felt obligated to perform whatever kind of music his audience
               wanted (Baraka, personal interview, June 20,
                  2019). He performed some “world music” (by which he meant secular music)
               against his will to earn a living, and he seemed to carry some guilt from that
               experience. But Baraka also performed and recorded gospel music with his family, and
               the videos were sold to supplement family income. Since coming to the US, he has
               stopped performing “world music” because he believes the purpose of music is for the
               glory of God and nothing else. This self-imposed restriction is rooted in his
               personal beliefs. He believes his resettlement in the United States is God-given
               gift, and he is unapologetic about confining all music making to church-related
               activities only (Figure 2). God has blessed him, he said, with a job that pays for
               his expenses and leaves a little leftover for studio fees whenever he has a song to
               record.</p>
            <fig id="fig2">
               <label>Figure 2</label>
               <caption>
                  <p>Baraka (2nd right) leads other performers at his local church in Phoenix,
                     AZ.</p>
               </caption>
               <graphic id="graphic2"
                  xlink:href="Pictures/10000000000005A0000003C0C031B63FFF492698.png"/>
            </fig>
            <p>DJ Grin and MC Joel were taken to a Ugandan refugee camp as children. They lived in
               Uganda as musicians and were eventually resettled in the United States. They both
               reported using music to educate, inspire, and entertain refugees at the camp, and
               some of those songs are posted on their YouTube channels (DJ Grin the peacemaker,
               n.d.; MC Joel, n.d.). When interviewed, DJ Grin mourned the loss of his media
               following and his inability to access television and radio in the US. He viewed his
               resettlement as a “backsliding” in his musical career because he lost the audience he
               worked hard to garner for himself while in Uganda (DJ Grin, personal interview, April 12, 2019). Like Furaha
               and Baraka, DJ Grin and MC Joel have difficulty getting the kind of audience they had
               in Uganda. Despite these drawbacks, they have continued to seek opportunities to
               perform music, adapt their styles, and integrate themselves and their families into
               communities in the United States.</p>
            <p/>
            <p>Don Brighter was born in Burundi but moved to Tanzania with family to flee violence
               in his home country. He recalled enjoying Zulu music that was played over and over on
               a radio station. He defined music as a language that communicated “without even
               having to say a word that somebody can understand” (Don Brighter, personal interview, April 27, 2019). Don later
               left Tanzania, was resettled in the United States, and recently graduated with a
               criminal justice degree. Initially after resettlement, he worked for Catholic
               Charities (an agency that helps with refugee resettlement), but he eventually left
               that job to focus on his music. Don recognizes that Americans appreciate songs in
               English even though he thinks the language should not matter, so he writes some songs
               in English. He also writes songs in Kiswahili and Kirundi or, as in his song
                  <italic>Fire Fire</italic> (Figure 3), mixes languages, which is a common practice
               among Tanzanian youth (<xref ref-type="bibr" rid="E2008">Englert, 2008</xref>). Don’s
               music is similar to other Bongo Flava artists who fuse material from a variety of
               genres, including hip-hop, rumba, reggae, soukous, and Western styles (<xref
                  ref-type="bibr" rid="RJ2014">Reuster-Jahn, 2014</xref>; <xref ref-type="bibr"
                  rid="S2013">Sanga, 2013,</xref>, <xref ref-type="bibr" rid="S2011">2011</xref>;
                  <xref ref-type="bibr" rid="S2005">Stroeken, 2005</xref>). He also indicated that
               he performs Afropop and rhythm and blues. For Don, history tells him that music is a
               language because, as a child, he “understood” Zulu music without knowing the Zulu
               language. Experience has taught him that openness to style and language change is
               wise for the audience in the United States. Like other study participants, he stands
               between Africa and the West and identifies as a citizen of the United States and as
               an African.</p>
            <fig id="fig3">
               <label>Figure 3</label>
               <caption>
                  <p>Don Brighter (right) performs a romantic piece Fire Fire with a female
                     companion. Available on YouTube (Don Brighter, n.d.).</p>
               </caption>
               <graphic id="graphic3"
                  xlink:href="Pictures/1000000000000F000000043877A2A60AE25C9650.png"/>
            </fig>
            <p>Zau was the only participant from outside of Africa. He was born and raised in
               Myanmar but escaped the violence there and was later resettled in the US. He learned
               to play guitar and compose music from a private tutor in Myanmar. Zau devotes his
               time to gospel music and is a pastor of the Myanmar Christian Church, a community of
               people from Myanmar and Nepal who worship together on Sundays. While recognizing that
               Asian and American music types are entirely different, he described his style as
               modern rock even though his music does not closely resemble American rock. Like Don
               Brighter, Zau believes that music is a language, but he also recognized that his
               limited English proficiency, along with stylistic differences between Asia and the
               West, impact his music performance in the United States. However, he has an audience
               at his church that understands his language and appreciates his music performance
               style (Zau, personal communication, April 30,
                  2019). Therefore, he is not presently targeting outside American
               audiences.</p>
         </sec>
         <!-- sec lvl 3 end -->
         <!-- sec lvl 3 begin -->
         <sec>
            <title>A Sense of Loss</title>
            <p>One of the most salient observations from the interviews was that participants
               experienced serious personal loss because of displacement, flight, and resettlement.
               For example, the loss of Furaha’s home in the DRC was quickly followed by the need to
               leave her home country to protect her children. This decision resulted in the loss of
               contact with many close relatives and friends. From a music making standpoint, she
               had to acculturate to the new environment in Kampala, Uganda, before she could begin
               to attract a new audience with revised music, some of which is posted on her YouTube
               channel (Furaha Nsimire, n.d.). In 2017, she was lucky to be resettled in the United
               States, which increased her safety and ability to work and earn her living. However,
               the United States environment did not provide reliable enough performance
               opportunities to generate an income from music performance. She accepted a job as a
               caregiver, but she and her children, including Baraka, perform music at community
               events and at their local church. Their performances in the United States are not
               presently aimed at generating income; they are more for psychological wellness,
               community service, and evangelization. For examples of Furaha’s songs after
               resettlement in the United States, visit her YouTube channel (Furaha Nsimire.F,
               n.d.). As another example of loss, shortly after the first interview for the current
               study, DJ Grin lost his mother and was unable to return to the DRC to attend her
               funeral because of safety, legal, and economic barriers.</p>
            <p>Participants also felt a sense of loss from their inability to take advantage of
               developed skills to their economic and social benefit after the change of
               sociocultural environment because of resettlement. Both DJ Grin and MC Joel lost
               their substantial and growing audience in Uganda after resettlement, but they are
               starting to establish new audiences in the United States. DJ Grin verbalized the
               shared feeling that Americans do not appreciate refugee talent when he stated, “you
               are only known as a refugee, that’s it” (DJ
                  Grin, personal interview, April 12, 2019). He wants to also be known as a
               musician, a father, a leader of a youth talent group, and a husband, not simply as a
               refugee. Don Brighter recognized there was less interest in his variety of music,
               i.e., Bongo Flava, Afropop, and rhythm and blues, which was compounded by the need to
               write songs in English. Like other study participants, Don was searching for a middle
               ground that embraced his background and the United States cultural, linguistic, or
               musical elements. On the other hand, Zau was less concerned about fitting into the
               broader United States environment and was instead focused on serving the Myanmar
               Christian Church in Phoenix, Arizona. But he recognized this focus as a barrier to
               community integration which limited his ability to exploit his full potential in the
               United States.</p>
            <p>The above examples of the sense of loss are not comprehensive because the experience
               of loss differed greatly between participants in terms of what they missed the most.
               Some participants grieved over the loved ones in their home countries or in refugee
               camps outside of the United States that they missed. Also, there were variable
               degrees of grief about their musical talents that were less appreciated in the United
               States than elsewhere because of stylistic, linguistic, and cultural reasons related
               to the meaning and role of religion. Some felt a loss of time they would normally
               dedicate to music making that was instead taken up by having to work in other
               industries to earn a living. As such, they had limited time for music. Additionally,
               five participants wished they could use the less expensive recording studios outside
               the US, which met their needs and enabled them produce better quality recordings.
               Whatever the loss experienced by participants, they all felt a strong sense of having
               lost something of substantial emotional, economic, or cultural value.</p>
         </sec>
         <!-- sec lvl 3 end -->
         <!-- sec lvl 3 begin -->
         <sec>
            <title>Adaptation and Change</title>
            <p>It is difficult to appreciate the determination of the participants to maintain their
               music performance activity without looking at how they adapted to changing
               environments. Rather than give up music performance, they changed to better respond
               to new cultural contexts. Furaha and Baraka started their music making in the DRC,
               but then in Uganda they performed new songs in Kiganda and Kiswahili before they left
               Africa. They are now trying to find their place in the American environment. Looking
               at their YouTube channel (Furaha Nsimire, n.d.) shows that Furaha and Baraka have
               experimented with all kinds of genres, such as hip-hop–styled Christian music, which
               is very different from the gospel music from Eastern Africa they appear to be most
               familiar with. They have sung in nearly half a dozen languages between the DRC,
               Uganda, and the United States. Similarly, DJ Grin, MC Joel, Don Brighter, and Zau
               have had to deal with change and adaptation. They have changed styles and languages
               based on their location but have always found a way to integrate African or Asian and
               Western idioms. Looking at their YouTube channels (Brighter, n.d.; DJ Grin the
               peacemaker, n.d.; MC Joel, n.d.), one sees a collection of musical styles that
               include popular gospel, Congolese rumba, Bongo Flava, rhythm and blues, Afropop, and
               hip-hop. There was a clear distinction between participants who mostly restricted
               themselves to gospel music, such as Furaha, Baraka, MC Joel, and Zau, and those who
               were more open to performing secular music, such as DJ Grin and Don Brighter.
               Openness to secular music, along with certain methods of choreography, may attract
               American audiences because the music is like styles and song themes already popular
               with youth in the United States. The change of style and language therefore
               characterized the experience of music between changing sociocultural contexts. </p>
         </sec>
         <!-- sec lvl 3 end -->
         <!-- sec lvl 3 begin -->
         <sec>
            <title>Benefits of Music Performance</title>
            <p>The fortitude to sustain music performance with low economic return (if not financial
               loss) must have underlying motivators. In general, study interviews suggested the key
               justification was related to the healing benefits of music. To fully comprehend these
               benefits, the root causes of healing that have a direct relationship with music
               experience must be examined. Since participants of the current study are refugees,
               they share the same experience of displacement as other displaced persons. Therefore,
               their use of music at refugee camps before resettlement and in the United States
               after resettlement is driven by the need to ameliorate serious health and
               environmental challenges. </p>
            <p>One way to use music to promote healing is to create a sense of hope in oneself and
               others. Doing so creates the belief, somewhat paradoxically, that things are
               currently all right and that they will be better in the future. Study participants
               appeared to consider music as the essential vehicle for conveying inexplicable
               messages to the depths of the human psyche, thus ameliorating the experience of
               trauma and emotional turmoil. Additionally, music created opportunities for community
               integration and enabled further healing from problems associated with isolation and
               loneliness. As such, the interrelated elements of recovery from trauma and emotion,
               communication, and community integration create the overall experience of healing
               from music performance (Figure 4). </p>
            <fig id="fig4">
               <label>Figure 4</label>
               <caption>
                  <p>Healing benefits of music performance.</p>
               </caption>
               <graphic id="graphic4"
                  xlink:href="Pictures/10000201000002F6000001EBE4907F80EBC68DD5.png"/>
            </fig>
            <p>
               <bold>Recovery and healing.</bold> This element is the primary reason for continuing
               to perform music when there are few economic benefits from the activity. Although all
               participants expressed in some way that music heals trauma and negative emotions,
               they expressed that belief differently. DJ Grin probably expressed it best when he
               defined music thusly: “music is life…music is unity…music is the medicine of trauma”
                  (DJ Grin, personal interview, April 12,
                  2019). This understanding of the healing benefits of music has practical
               implications. For instance, DJ Grin has sung songs to inspire, unite, and bring
               people with different backgrounds together; his song <italic>One People</italic> is a
               good example of this and is available on his YouTube channel (DJ Grin the peacemaker,
               n.d.). Don Brighter added another insight. He indicated that music does not take away
               one’s problems, but like a “painkiller” it helps to take away pain so that a person
               can “maybe forget about the problem even when the problem is not solved” (Don Brighter, personal interview, April 27,
                  2019). </p>
            <p>The trauma experienced by study participants was outside their control, but their
               resolve to use music to counter the effects of that trauma and other emotional
               problems showed that they perceived healing as being within their control. They
               believed that trauma could be ameliorated, if not completely removed, by making
               music. Although they were not directly questioned about whether they had considered
               psychological counseling, no participant stated, or even implied, that professional
               counseling had a place in their recovery. Perhaps they were unaware of counseling as
               an alternative or they had a better and cheaper method that worked for them. Through
               the healing power of music, DJ Grin went from traumatic childhood experiences, as
               indicated by his statement that “I was not born to see dead bodies,” to the present,
               where people wonder “why are you always smiling?” (DJ Grin, personal interview, April 12, 2019). The other
               participants indicated that music had healed their traumas and negative emotions in
               similar ways. They all had memories of horrific things that happened in their home
               countries, memories of loved ones left behind, and the experience of lacking basic
               things for survival. Any of these experiences can evoke fear or anxiety when not
               actively managed with care. Music is such a companion for decreasing emotional
               turmoil or sustaining hope in serious challenges that “it is hard to imagine life
               without music” (DJ Grin, personal interview,
                  April 12, 2019).</p>
            <p>
               <bold>Communication.</bold> Study participants used their music to communicate to
               targeted groups, including themselves. Don Brighter spoke most eloquently about
               customizing messages to match a situation. He indicated that the purpose of music is
               to communicate, but unlike speech, he saw music as a more potent means to communicate
               everything from political ideas to romantic ideas to deeper messages that no words
               were able to express. To him any experience of music that generated or restored
               wellness was a sign that a message, incomprehensible as it may be, was communicated.
               Often, it happens with words (song texts), but sometimes it happens without words. MC
               Joel also used music to regulate emotions. For instance, he sometimes used headphones
               to filter everything else out, so he could direct all his attention to music. MC
               Joel’s song <italic>Neema</italic>, available on his YouTube channel (MC Joel, n.d.),
               captures his philosophy about how to respond to adversity. The grace of God, he says
               in <italic>Neema</italic>, is enough no matter what the problem is (Figure 5). By
               that, he means grace is enough to endure any kind of pain. The song also stresses
               that it is not by anyone’s intelligence, power, or wealth but by the grace of God
               that that things are as they are; therefore, it is always important to be grateful to
               God.</p>
            <fig id="fig5">
               <label>Figure 5</label>
               <caption>
                  <p>MC Joel performing Neema which means “grace” (of God). There is a video
                     recording of this song in his YouTube channel (MC Joel, n.d.).</p>
               </caption>
               <graphic id="graphic5"
                  xlink:href="Pictures/1000000000000F00000004387812B36D50980428.png"/>
            </fig>
            <p>MC Joel and DJ Grin used music to educate, inspire, encourage, and instill hope in
               other refugees at the camp in Uganda. They did this as a charity to help their fellow
               refugees remain hopeful, positive, and dedicated to whatever they had to do to
               survive. In the song <italic>Amkeni</italic>, available on his YouTube channel (MC
               Joel, n.d.), MC Joel tells his audience, the refugees at the camp in Uganda, that
               there was no place for idleness and sloth, and he urged them to wake up and work
               hard. Furaha, Baraka, and Zau have also inspired their audiences in the DRC, Uganda,
               Myanmar, and the United States, respectively, but their inspiration is rooted in
               Christian teachings. In the song <italic>Igwe </italic>that Furaha performs with
               Baraka and her other children, they tell their audience that God has all power and
               rhetorically ask, “Father you can break all tents, why should I fear?” (Furaha
               Nsimire, n.d.). Furaha, Baraka, Zau, and to some degree MC Joel limit themselves to
               writing gospel songs. Despite differences in beliefs, study participants used music
               to convey messages of hope, peace, and solidarity among all peoples. Further, they
               were conscious of potential differences in race and culture among their audiences and
               hoped for a more united, loving, and peaceful world. </p>
            <p>
               <bold>Integration. </bold>As the participants moved from nation to nation, the
               performance of music appeared to be the means of connecting with residents in the new
               places where they settled. However, this connection was not always successful because
               language, cultural, and economic factors limited or slowed down the process.
               Therefore, the participants used music to share their values and promote what they
               regarded as valuable and true. They also used the opportunities arising from their
               skills to integrate better into communities and to meet new friends. For instance,
               Baraka felt that the performance of music earned him respect among his new
               acquaintances who were from diverse backgrounds. </p>
            <fig id="fig6">
               <label>Figure 6</label>
               <caption>
                  <p>DJ Grin (second from right) with fellow artists after performing at the
                     Coast2Coast Miami competitions on August 31, 2019. DJ Grin travels widely in
                     the United States to perform music in community gatherings.</p>
               </caption>
               <graphic id="graphic6"
                  xlink:href="Pictures/10000000000002D0000003C0D426AED39730533F.png"/>
            </fig>
            <p>During the study, DJ Grin and MC Joel were participants in large musical talent
               competitions (see www.coast2coastlive.com). At those competitions, they met other
               artists and competed for sponsorships. After winning second place at his local
               Coast2Coast audition, DJ Grin was sponsored to perform at the Coast2Coast Miami
               competitions; his performance is available on his Facebook Live account (<xref
                  ref-type="bibr" rid="DJG2019">DJ Grin the peacemaker, 2019</xref>). This
               competition also enabled him to meet other artists (Figure 6).</p>
            <p>For participants of the current study, the pattern of engagement with the community
               has the potential to popularize their music and open new avenues for growth of their
               talents. It also has the potential to facilitate a return to music careers as their
               primary source of income. The performances of participants create avenues to learn,
               connect with fellow artists, and find possible future collaborators. For instance,
               Zau has used his music skills to promote his evangelistic ministry at the Myanmar
               Christian Church, which includes immigrants from Myanmar and Nepal as well as people
               from other parts of the world, including the United States. All study participants
               have been performers in local community events in the United States, and it is their
               performance of music that has created these contacts and a new audience. Although
               this audience may be limited when compared with their African or Asian audiences, it
               still promotes their integration and possible popularization in the United States’
               communities. Ultimately, their music has decreased their isolation and increased
               opportunities for success in the United States.</p>
         </sec>
         <!-- sec lvl 3 end -->
      </sec>
      <!-- sec lvl 2 end -->
      <!-- sec lvl 2 begin -->
      <sec>
         <title>Conclusion</title>
         <p>For the six participants of the current study, there was a clear indication that the
            performance of music was very meaningful when dealing with trauma, anxiety, and other
            negative emotions. Performing music helped them deal with trauma in three ways. First,
            music had the effect of calming serious negative emotions and memories of traumatic
            experiences. Many can relate to the use of music to regulate emotions and enhance
            wellness because it is a healthy way to engage the mind and distract from detrimental
            thoughts and memories. Second, music was used by the participants to communicate a
            message of hope with themselves and others during a time of doubt, fear, and anxiety.
            The value of these messages is related to both content and context. This distinction is
            important because only those who have traumatic memories and anxieties from similar
            lived experiences can appreciate the participants’ messages in a comparable way.
            Furthermore, musically communicating to inspire others was seen as a charitable activity
            by participants. They considered it as an offered gift of musical counsel and a “treat”
            for the community. This outlook had the benefit of creating a sense of accomplishment
            and value in the participants and in others. Third, music helped them deal with trauma
            by providing opportunities for integration into their new communities in refugee camps
            or in the US. Because of their experiences, participants are at a high risk of
            marginalization and isolation. The necessary departure from their home countries
            resulted in the loss of numerous social ties and usually required them to learn a new
            language and embrace a new cultural context through the process of assimilation. </p>
         <p>The study suggests that music performance can be very helpful in facilitating the
            integration of refugees into communities in the United States. Music can be the key for
            opening new avenues for collaboration in artistic ventures. Furthermore, we see gifted
            musicians among refugees in the United States who can be instrumental in relieving
            stress associated with traumatic experience shared by many refugees. Therapists, social
            workers, case managers, and other professionals working in communities where these
            individuals are resettled should consider ways to use creative talents in individual or
            group interventions to promote wellness, decrease isolation, and enhance community
            participation. Resettlement agencies should also consider developing more programs that
            use the creative talents of refugees to improve health, economic status, and integration
            outcomes.</p>
      </sec>
      <!-- sec lvl 2 end -->
      <!-- sec lvl 2 begin -->
      <sec>
         <title>Acknowledgements</title>
         <p>The author would like to acknowledge the following people for their assistance. My wife
            Jennifer Muriithi, founder and director of Tapestry (an organization that serves
            refugees), was a partner in the data collection and was very helpful with obtaining
            contacts from her work with refugees in the Phoenix area. Linda Materu, research
            assistant and occupational therapy doctoral student at A.T. Still University,
            transcribed all interviews verbatim and translated interviews done in Kiswahili into
            English. Deborah Goggin from research support at A.T. Still University edited original
            manuscript and suggested modifications for improvement.</p>
      </sec>
      <!-- sec lvl 2 end -->
      <!-- sec lvl 2 begin -->
      <sec>
         <title>About the author</title>
         <p>Bernard Austin Kigunda Muriithi is an assistant professor of occupational therapy at
            A.T. Still University, Mesa, Arizona. He is a Kenyan musicologist whose PhD research,
            completed at Otto-von-Guericke University of Magdeburg – Germany, focused on the
            relationship between music and health in multiple Kenyan contexts (including traditional
            rituals, Christian rituals, and Nairobi street musicians). He presently works as an
            occupational therapist, educator, and interdisciplinary researcher in the United
            States.</p>
      </sec>
      <!-- sec lvl 2 end -->
   </body>
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               <uri>https://www.unrefugees.org/refugee-facts/statistics/</uri>
            </element-citation>
         </ref>
      </ref-list>
   </back>
</article>
