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 (Bensimon et al., 2008; Lauzon, 2019; Orth, 2005; Zharinova-Sanderson, 2004). Yet, recent studies show that refugees and asylum seekers are under increased risk of developing common psychiatric disorders, such as depression, anxiety and post-traumatic stress disorder (PTSD), as well as an increase in disabling symptoms of psychosocial stress due to their dramatic experiences before, during, and after the flight (Gonsalves, 1992; Hassan et al., 2016; Hebebrand et al., 2016; Laban et al., 2004; Marquardt et al., 2016; Metzner et al., 2016). Additionally, difficult living conditions can have a negative impact on the ability of refugees to cope with their traumatic experience (Carswell et al., 2011). Particularly war-affected refugee children and unaccompanied asylum-seeking adolescents are under risk of developing mental health problems, making them more vulnerable to the exposure of community violence, domestic violence, and physical and emotional abuse even past the resettlement period (Betancourt et al., 2012; Guruge & Butt, 2015; McGregor et al., 2015).

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 (Abdulbaki & Berger, 2020).

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 (Lauzon, 2019; Orth, 2004).

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 (Mediendienst, 2020).

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 – COntext-sensitive classification model for music therapeutic interVEntions with Refugees” which we would like to introduce to the music therapeutic community as a tool for music therapeutic interventions based on the natural living environments of refugees.

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 (Champine et al., 2019) and to enable the patient to focus on their own symptoms, personal resources and needs.

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 (Gonsalves, 1992). Gonsalves describes five stages of arrival in relation to therapeutic interventions. In stage one, (“Early Arrival”) orientation, diminishing confusion and preventive strategies with culturally acceptable interventions are primary. Bridging the transition from the homeland to the host country is the declared goal. It also points out that natural settings in which the refugees gather should be used rather than external surroundings, which is in line with our concept and approach to provide music therapy at the reception centres and camps directly.

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 (Pelletier, 2004; Walworth, 2003) as well as PTSD symptoms during group music therapy sessions (Bensimon et al., 2008).

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.

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 (Betancourt et al., 2010, 2012). An early intervention after traumatic events is crucial in order to prevent a chronification of trauma (Oral et al., 2016). Even though not every refugee is affected by trauma, providing or adapting the setting according to the trauma-informed approach seems recommendable. Safety in the process and structures for orientation, e.g., at the start and the end of each music therapy session help the participants. Creating a safe therapeutic environment to allow the participants to express their personal thoughts and feeling seems crucial.

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 (Sutton & De Backer, 2009). Music can be considered a universal language concerning its function as a communicator for emotions and personal expressions. Especially the social functions of music such as contact and empathy with and for others, increase of well-being, cooperation, synchronization and increased social cohesion of a group define music therapy as a perfect method of early therapeutic intervention (Koelsch, 2015). The connecting elements of music help to create an atmosphere of familiarity and trust even in unfamiliar surroundings and allow for emotional expression and regulation through active music making. Using our COVER model and applying the music therapy interventions to the natural living environment of the refugees allows for an early intervention and may be a crucial benefit to the psychological health of refugees.

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.