Due to the difficult situation of refugees, working with this group is challenging.
Yet, music therapy is a suitable method for early therapeutic intervention. The
authors introduce the
Literature and research on music therapy with refugees and asylum seekers has been
mainly focusing on the clinical settings, music therapeutic methodology and
interventions which start rather late during the process of arrival (
Therefore, an early support for mental health care needs and early therapeutic
interventions seems necessary. Yet, therapy onset faces a lot of challenges such as a
lack of therapists, language barriers, lack of trained interpreters, lack of cover for
therapy costs or reservations against any form of therapy. Music therapy can provide a
culturally-centred, low-entry threshold approach in the treatment of mentally affected
refugees from an early stage of arrival onwards (
To the best of our knowledge, no concept on early interventions in different settings
with music therapy for refugees and asylum seekers has been made public. However, a
number of music therapeutic interventions with refugees such as singing, song writing,
instrument play, improvisation, lyric analysis, music listening, music imagery and
music-based relaxation have been proven ideal for this group (
In Germany, numbers of asylum seekers increased from 202,834 in 2014 up to 745,545 in
2016 due to the ongoing conflicts in Syria, Iraq, Afghanistan and Eritrea, creating a
high demand for health care, social and psychological support among those seeking
shelter (
Therefore, the Musiktherapie-Initiative e.V., a German non-profit association of trained
music therapists located in Hamburg, started to provide music therapy for refugees and
asylum seekers in refugee reception centres and follow-on camps. The experiences gained
from 2013 to 2018 led to the development of the “COVER Model –
The
Additionally, consideration of the multi-cultural aspects in therapy as well as the
music therapist’s reflection and evaluation of the instruments and music used in
music therapy seemed necessary in order to offer the participants ways to express
themselves (
The COVER Model
As every setting presented its own challenges for the music therapists, the participants also presented the therapists with different needs depending on the setting. Therefore, each of the three settings was labelled based on what was perceived and observed as the most important task for the music therapist and needs of the participants working in the setting (inner circle).
Open group sessions were labelled “Listen to me” for the ’need to be seen’ seemed to be the main topic within the refugee reception centres. The task of the music therapist was to ensure that each participant was heard and given the same attention. Feelings of sadness, hopelessness, hopefulness, expectations, frustrations and being lost were perceived strongly by the music therapist. Coping with the large amounts of mixed feelings experienced by the music therapist was a challenge.
The label “Listen to each other” was given to small group sessions which were mainly used in follow-on camps. The setting allowed for a smaller group size and more privacy. The focus could turn more towards the present topics such as language barriers, homesickness, worries about loved ones etc. Working in this setting with participants from similar background allowed the groups to “Listen to each other,” to give everyone their own space and time to share experiences.
Individual therapy sessions were labelled with “Listen to yourself” and normally applied
within an outpatient setting. The ITS allowed for a more in-depth therapeutic approach
and provided enough security to address conflict-related topics. The sessions took place
weekly and provided a secure therapeutic relationship. Moreover, the safety of this
setting helped to prevent re-traumatization (
In the following section a short description for each kind of session, its aim and structure, music and special aspects, as well as case examples are provided. Table 1 also gives an overview.
Overview of the music therapy sessions
Open Group Sessions |
Small Group Sessions (SGS) | Individual Therapy Sessions (ITS) | |
---|---|---|---|
Label | Listen to me | Listen to each other | Listen to yourself |
Setting | Initial reception centre | Follow-on camps | Outpatient therapy setting outside camps; schools |
Group form | Open and improvised | Open group with more consistent members | One-on-one |
Number of participants | 2-45 | 12 | 1 |
Duration | 60-120 minutes | 60 minutes | 50 minutes |
Participants | Mixed; mainly young men and children, some women | Men (with similar cultural background) or children | Individual |
Acquisition of participants |
Written announcements in different languages, verbal invitation by music therapists | Written and verbal invitation by social workers and music therapists | Consultations with school teacher/doctor/psychiatrist |
Concept | Instrument building workshops |
Low entry threshold music therapy group | Psychodynamic music therapy (with focus on trauma-based music therapy) |
Role of the music therapist | Facilitator/guide | Guide/therapist | (psycho-)therapist |
Goal / intervention | Empowerment |
Supporting |
Being in the ‘here and now’ |
Music | Circle songs |
Songs from the country of origin |
Connected to the individual’s emotional state |
Instruments | Small instruments |
Small instruments |
All general music therapy instruments |
OGS are defined as either a one-time open group or repeating open group session
once a week. This included one-day instrument building workshops, weekly open
drum sessions and fortnightly open circle singing sessions. The sessions were
improvised due to the number of participants, the group dynamic, and the
individual resources and needs. Most of the participants were men. Working in
this setting was characterized by freedom to come and go. The groups were
half-open (due to newcomers and others leaving the camp) and needed great
flexibility. The place and time for the group could vary also due to external
influences. The number of people attending OGS varied immensely between 2 to
45. Empowering participants, discovering one's own resources, establishing contact among the camp members and allowing space for individuality were the main interventions. To provide
more structure to the session, songs were repeated often. Participants were
welcome to introduce songs, rhythms or dances of their own to encourage musical
participation and social inclusion (
In this particular setting and during the sessions, music therapists were challenged to incorporate the multicultural backgrounds of the participants. Yet, the multinational group, however, shared knowledge of the same songs like Shakira’s “Waka Waka” due to the soccer championship or “We will rock you.” As a result, these songs were sung during almost every session regardless of one’s nationality, gender and age. In the singing group the repertoire included pop songs, African canons, simple German folk songs or songs from the home countries (e.g., in Farsi or Arabic). The African canons included only up to four words and were learned by the whole group as something new together.
Using songs in the participant’s language led to self-empowerment and change in the group dynamics as well as between therapists and participants. Teaching the right pronunciation caused many moments of joy and allowed the ‘teacher’ to stand out. The songs were accompanied by small percussion instruments and body music (e.g., hand claps and stamping of feet) and movements. For some participants it was very difficult to hold a rhythm with their body or coordinate movements. Therefore, the rhythms were kept very simple.
The participants took turns in singing and improvising a verse with great pride in their performance. Participants wanted to distinguish themselves in some way either by showing off musical skills, leadership or simply through the volume of playing. We interpreted this behaviour as a strong need to be recognized as more than just a refugee.
Case Example |
---|
During all the sessions the participants started dancing freely.
Short dance competitions occurred, where two or three persons
danced in the middle of the circle and the rest could applaud or
simply watch and be part of the event. Ahmed
|
SGS are defined as a small, more consistent, weekly group sessions with 12 participants. Participants had a similar cultural background and stayed for a full session. The sessions were clearly structured and took place in a room within the premises.
Supporting, grounding and mirroring were the main interventions during the sessions. The participants were supported to choose instruments and communicate their wishes and needs. Within the group the music and the safety provided through the setting allowed participants to give more insight into their emotional state.
Sharing the same cultural and religious background seemed to speed up the group formation process and helped the participants familiarize with each other to the new or unknown form of music therapy. It provided music in a ‘natural way,’ meaning that participants quickly joined when one participant started singing a song from the country of origin. The growing sense of familiarity presented the opportunity for the participants to show some of their emotions. In these cases, the music functioned as a ‘door opener,’ meaning the music empowered therapists and clients to bridge the cultural gap and allowed them to connect with one another. During the sessions, the participants wanted to produce a “nice” piece of music, e.g., without dissonances. In many cases, rhythms were complex, and polyphony and quarter tones were common. On the other hand, moments of silence were greatly avoided and considered unbearable by many of the group’s participants.
Case Example |
---|
A group of 12 men with Syrian and Afghan background caught interest in the music therapy project which had been running on a weekly basis in the camp and was mainly addressing children. In order to start a new group with the male adults, the children had to understand that the new group was not an addition to their running group. Yet, the children would not allow the men into ‘their’ space (the music room) and interrupted the process constantly by entering the room and protesting loudly. In addition, the men contributed great effort to make the room their own for the time of the group by setting it up with chairs, instruments and organizing an alternative activity for the children during the time of the group. The initiative and determination of the participants to engage was validated and started an instant group process which allowed the participants to share current and past experiences on a deeper level. |
ITS
As is the case in any individual therapy, there can be no general description of its content or music. However, in many cases, the music could be described as chaotic at the start and contained a large variety of emotions, which also evoked strong emotions within the therapists. Yet, expressing the inner emotional state was often difficult due to the lack of a common language. It was therefore indispensable for the music therapist to carefully intervene and guide the client through the sessions and to contain the situation.
Also, talking about one’s problem with a trained therapist of any kind was a new experience to many participants. Certain fears, e.g., risking the chances for asylum by giving away personal details, fear for family left in the home country, or general mistrust at the beginning towards the therapist or method, made the process difficult.
During the music therapy sessions participants seemed to prefer instruments
from their cultural background. We observed that string instruments were often
used by Syrian, Afghan, Iranian or Iraqi participants, any kind of drums by
participants from Eritrea or Somalia, and tabour or goblet drum by Syrian or
Afghan participants. These instruments could represent a familiarity and
provide a connection between the new and old culture. A tendency for regression
was observed while participants played these instruments, meaning, as a defence
mechanism, the person temporarily went into an earlier developmental state in
order to cope with psychological stress which may be brought up by the familiar
sounds of the instruments (
Case Example |
---|
Ali is a 9-year-old boy from Eritrea who fled across the Mediterranean with his family. He receives music therapy for 3 months. He does not talk much to the therapist and is easily scared. The music therapist gained his trust slowly. In the music therapy room there is a tipi, serving as a safe and hiding place within the room. The tipi has two small windows. A repeating scene could be described as follows: Ali chooses the djembe at the beginning of the session and drums loud and furiously on the djembe. The music therapist not being allowed to play the same instrument, chooses the piano in order to be loud enough and to signal Ali he is not alone in the music as well as offering a structure and a contrast. The music therapist has to keep her distance. Ali needs space. Close by him there is the hand puppet lion which often comforts him. After a loud an intense drumming Ali stops, places the lion in front of the tipi, disappears inside it and closes the ‘door’ behind him. The music therapist, still at the piano, improvises the music according to the situation. The impulsive, loud music from the beginning of the session slowly turns into a quiet and comforting, melodic sound. Ali’s only sentence in this session follows a few minutes after he disappeared in the tipi: “I want to sleep”. The music therapist then starts to play and hum a German lullaby softly on the piano. |
The COVER model is a first attempt to describe music therapy with refugees based on the natural living environment such as refugee reception centres with large numbers of people, follow-on camps with generally fewer people, and an outpatient setting. As we experienced a distinct difference of feasible interventions due to rules and regulations in each setting, the applied music therapy concept had to change according to the natural living environment. Hence, our model uses the setting in which music therapy takes place as its initial point and uses different interventions in each session according to what each setting offers.
As refugees go through different stages in the resettlement process over time, the
therapeutic interventions, as well as the therapist’s role, the refugees tasks and
treatment change by the length of time since arrival in the new country (
The music therapeutic interventions applied under “Listen to Each other” also
incorporate many of Gonsalves’ aspects for stage two (“Destabilization”) and three
(“Exploration and Re-stabilization”), which describe the time of confrontation with the
new culture as well as a mixture of feelings, e.g., anger, sadness, loneliness,
homesickness, isolation and anxiety about failures. Gonsalves points out that
connections to other refugees are crucial for maintaining feelings of continuity with
the past, and an openness towards the new culture is needed to master this phase. In
SGS, a closer connection among the participants was evident. The smaller group sessions
provided safety to the participants and allowed to create stronger bonds between the
group members and the music therapists. Also, we used the positive influence of music in
reducing stress levels and anxiety (
In our model, the label “Listen to yourself” generally refers to the time after the refugee camps or follow-on camps, when a safer environment is established and an understanding of the new culture’s norms and values starts to emerge. Confrontations with the past and present were common during that stage and refugee patients who needed more in-depth treatment to overcome their past had the chance to integrate their experiences and address inner conflicts within this individual outpatient therapy setting.
The model is based on observations during the music therapy sessions portraying only a certain extent of the challenges and difficulties experienced by the participating refugees and music therapists.
Also, most of the group’s participants were male or children. Women did not join the groups as regularly and no solely female group could be established. Therefore, our observations apply mainly to male participants and children. Cultural boundaries, social roles and thresholds may need to be investigated further in order to apply the model to women.
There can be no doubt that many refugees are in need of therapeutic support. Access to
mental health services is often difficult and community-based and preventive
interventions with family or peers seem most advisable (
The limited access to mental health facilities, language barriers and the lack of
available interpreters call for the use of creative arts therapies such as music
therapy. Music therapy is preferable for interventions when communication through spoken
language is unavailable (
Tina Mallon, music therapist M.A. has studied psychology and musical education in Erfurt and music therapy in Hamburg, Germany. She is one of the founding members of the Musiktherapie-Initiative e.V. Since 2013, she has been working with refugees and traumatized children. She is also a research scientist working at the Department of Primary Care at the University Hospital Hamburg-Eppendorf.
Monika T. Hoog Antink studied creative therapy with special focus in music in Nijmegen, The Netherlands, followed by a master’s degree in music therapy in Hamburg, Germany. She works with children with severe to profound disabilities, in palliative care and dementia care. Currently, she is involved in a research project on how to develop music therapeutic research methods for children with severe to profound disabilities.
All names and other personal characteristics of the patients described herein have been altered in order to protect their identities.
ITS are part of the model that have not yet been accomplished through the work of the Musiktherapie-Initiative e.V. but through work in clinical or ambulatory music therapy settings.