Music Therapy with Active-Duty Service Members: Group Protocol Description and Secondary Analysis of Protocol Evaluations

Abstract

Based on the growing need for music therapy programming at military treatment facilities and clinics that specialize in the rehabilitation of service members, this article describes a music therapy group protocol and the findings of 201 post-session evaluations. In addition, we present clinical perspectives and recommendations from three music therapists who have facilitated this group protocol on four military bases across the United States. The group session outlined in the protocol is intended as an introduction to music therapy. It familiarizes service members to various music therapy experiences specifically structured to enhance feelings of safety during emotional risk-taking. In addition, the protocol functions as an initial assessment of service members’ responses to the various receptive and interactive music experiences and includes psychoeducation regarding the role of music therapy in an interdisciplinary treatment model. The post-session evaluation data suggest that service members endorsed this introductory group as moderately to very helpful. Perceived benefits included the opportunity to express various emotions and increased awareness of somatic responses through music. A large number of requests for continued music therapy services following the introductory session suggest that the protocol is successful in facilitating understanding in service members regarding the potential benefits of music therapy in interdisciplinary treatment. Feedback from the music therapists indicated that the group protocol is a helpful initial experience for service members to acclimate to music therapy and for music therapists to learn about their patients’ specific needs to inform subsequent treatment.

music therapy, military, traumatic brain injury, post-traumatic stress, group protocol, evaluation

Introduction

Music therapy has historical roots in military settings (American Music Therapy Association, 2014; Taylor, 1981) and is provided as clinical treatment throughout the Department of Veterans Affairs (VA) and the Department of Defense (DoD) in the United States (US). Traditionally, in the VA, board-certified music therapists have been positioned under Recreation Therapy departments; however, in the DoD, music therapy is aptly integrated as a clinical offering in interdisciplinary treatment programs along with other creative arts therapies and traditional rehabilitative and medical services (Bronson, Vaudreuil, & Bradt, 2018). Music therapy is well-positioned to serve active-duty military personnel, veterans, their families, and caregivers in individual and group sessions to support ongoing treatment, as well as assist other clinicians in interdisciplinary and multidisciplinary co-treatment settings (Vaudreuil, Avila, Bradt, & Pasquina, 2019). Several studies conducted on the use of music therapy with military personnel, veterans, and civilians with post-traumatic stress disorder (PTSD) have yielded beneficial treatment effects. For example, music-based relaxation has been shown to reduce symptoms of depression and insomnia in people with posttraumatic stress (Blanaru et al., 2012), both of which are symptoms commonly experienced by military populations. In addition, music listening has been effectively used as a tool for self-management of emotional and cognitive issues with veterans (Zoteyeva, Forbes, & Rickard, 2016). However, these studies have not been exclusive to military-specific populations and have been conducted longitudinally, which indicates a level of patient access that may not be feasible across program models and clinics. Therefore, it is important that one-session protocols are developed and tested given the reality that some programs may have shorter treatment durations.

To ensure continued evolution of music therapy programs at military installations, it is important that program evaluations are conducted on treatment protocols developed by clinicians for use with military populations. Furthermore, it is imperative that protocols be shared with the wider music therapy community so that additional research can be conducted to test the efficacy and effectiveness of these protocols. Moreover, the publication of treatment protocols fits into the recommendations of the strategic plan for research by the American Music Therapy Association “Improving Access and Quality: Music Therapy Research 2025” (MTR2025), which states:

clinician researchers are a key component to expanding our understanding of music therapy among the spectrum of clinical and practice settings. Clinician researchers facilitate transdisciplinary research collaborations and serve as research ambassadors for the music therapy profession. From our use of evidence-based practice models to our active engagement in the research process, we serve as a bridge between the academic investigator and the clinicians’ world. (p. 36)

Support for music therapy with military populations comes from communities and local, state, and federal agencies. An initiative of the National Endowment for the Arts, (NEA) Creative Forces®: NEA Military Healing Arts Network, is a partnership with the U.S. Departments of Defense and Veterans Affairs and the state and local arts agencies with administrative support provided by Americans for the Arts. Creative Forces supports a continuum of clinical creative arts therapies and community arts engagement for military and veteran populations by employing creative arts therapists, specifically, music, art, and dance/movement therapists, to work with military populations across the US. As of 2019, Creative Forces supports nationwide creative arts therapies programming at DoD and VA facilities including a telehealth program that provides creative arts therapies using the principles of telemedicine. Creative Forces operates using three distinct pillars: (1) Clinical, (2) Capacity, and (3) Community, and strongly emphasizes research in all areas and across creative arts therapies disciplines (National Endowments for the Arts, n.d.). In the clinical realm, creative arts therapists use treatment protocols that can be replicated and adapted to meet the unique needs of their patients and clinic models across sites. Outcomes and impact of creative arts therapies are tracked using standardized clinical evaluation tools and documentation templates. This article presents a music therapy group protocol and the results of post-session evaluation data obtained from 201 service members. The intent of dissemination of this protocol is to provide didactic and applied information that supports the facilitation of an Introduction to Music Therapy group with military populations.

The Introduction to Music Therapy group protocol was first implemented as an initial group music therapy session in a 4-week Intensive Outpatient Program (IOP) at the National Intrepid Center of Excellence (NICoE), a Directorate of Walter Reed National Military Medical Center (WRNMMC) in Bethesda, MD. It was later implemented nationally in IOPs of varying length as well as longitudinal care models across Creative Forces sites. Many service members receiving treatment in these programs are on active-duty and have been diagnosed with mild to moderate traumatic brain injury (TBI) and associated health conditions, often due to combat operations. For many, it may be their first time receiving comprehensive, integrative care throughout military careers that span decades. To address the complex and unique needs of military populations, rehabilitation specialists tailor treatment plans focused on mind, body, and spirit, created with patient, family, and provider input. This treatment is offered through an interdisciplinary model that includes psychology, psychiatry, speech–language pathology, physical therapy, case management, medical services, other traditional therapies, and wellness programming. Music therapists work alongside team members providing stand-alone music therapy and co-treatment with other creative arts and traditional therapies in individual and group sessions (Bronson et al., 2018).

Due to the high prevalence of TBI, interdisciplinary music therapy treatment offered at Creative Forces sites is guided by principles of Neurologic Music Therapy (NMT) (Thaut & Hoemberg, 2014). Moreover, many service members who receive treatment at Creative Forces sites have been diagnosed with PTSD, and a recent study indicates that not all service members respond to traditional treatment methods such as cognitive behavioral therapy (CBT) (Steenkamp, Litz, & Marmar, 2020). A study that offered group music therapy to patients with PTSD who did not respond to CBT treatment indicated a significant reduction in PTSD symptoms (Carr et al., 2012). The group music intervention used by Carr et al. implemented a psychodynamic model of music therapy that mainly used improvisation and in-the-moment music-making. With the high comorbidity rate of TBI in military populations, a greater degree of musical structure may be needed to meet the patients’ cognitive as well as behavioral health needs (Gooding & Langston, 2019). Therefore, the Introduction to Music Therapy group protocol is also informed by a neurobiological understanding of PTSD (van der Kolk, 2000). The protocol was designed by a music therapist who had received NMT training and obtained a NMT fellowship. The interventions in this protocol are influenced by NMT techniques, including cognition, sensorimotor, and music in psychosocial training and counseling. NMT techniques are based on neurological, physiological, and psychological principles of music perception and production (Thaut & Hoemberg, 2014) and are supported by an evidence base. The protocol includes receptive and interactive experiences that facilitate awareness building and skill development through music-based relaxation, intentional listening, active music-making, and group processing. A post-session evaluation accompanies this group protocol. It is administered at the end of the group to obtain service members’ input about the perceived benefits of the session as part of standard evaluation procedures.

Intent of the Protocol, Implementation, and Evaluation

The intent of the Introduction to Music Therapy group protocol and evaluation is to: (1) deliver information to service members about music therapy, (2) introduce service members to various music therapy experiences, and (3) provide insight into music therapists regarding service members’ responses to the music therapy interventions. This protocol was designed by a board-certified music therapist who is NMT trained (R. Vaudreuil) and has 10 years of clinical experience working with military populations with TBI and PTSD. The protocol details how music therapy interventions are facilitated to assess needs, identify goal areas, and provide treatment aligned with interdisciplinary programming. Rehabilitation needs vary widely across military populations and those who receive care in an interdisciplinary capacity experience a breadth of treatments. This can present challenges in developing a protocol to implement across a spectrum of patients; however, group protocols are necessary in cohort-based programs (i.e., IOP) as music therapists often have limited access to service members during their course of treatment.

During the group session, service members are provided with an overview of music therapy through didactic and experiential facilitation and engage in interventions that address multiple domains of functioning. Specifically, the protocol is designed to: (1) reduce stress by inducing a relaxation response through promoting physiological entrainment; (2) introduce grounding and breathing techniques that service members learn to self-administer using musical accompaniment; (3) promote auditory discernment for self-awareness of sounds that promote well-being, elicit an impartial response, and trigger negative associations; (4) create a platform for group structured music-making, improvisation, and teamwork; (5) provide opportunities for activating varying levels of attention (sustained, divided, alternating) through engagement in rhythm-based exercises; and (6) initiate group discussion to promote mutual understanding among service members.

In addition to assessing psychosomatic responses and aspects of cognitive functioning, the group protocol allows music therapists to observe the level of cohesion in a given cohort of service members. This is essential within group models of care because service members often rely on peers for support throughout the treatment process. Early detection of challenging group dynamics enables the treatment team to develop strategies to enhance cohort cohesion. Across sites, the group protocol and evaluation are integrated in both IOP and longitudinal treatment tracks. In the IOP, the group protocol is often the first clinical encounter that service members have with music therapy, commonly facilitated in the first week of programming. In longitudinal treatment, the group protocol is also used as an intake session, facilitated on a recurring basis as service members are referred to music therapy. Using the group protocol as an initial encounter for newly referred service members assists the music therapist in creating a customized care approach by determining an appropriate treatment path for each service member, informed by clinical observations and evaluative outcomes.

The accompanying post-session evaluation seeks feedback from service members on the music experiences included in the protocol. Evaluation plays an important role in treatment planning as it allows therapists to gauge if their in-session observations coincide with service members’ self-report of their experiences and perceived impact of the interventions. Music therapists can rely on both clinical observation and evaluation responses to make informed recommendations for individualized and group treatment.

Introduction to the Music Therapy Group Protocol

The protocol consists of four components: (1) rapport-building and group introductions/check-in, (2) intentional, active music listening, (3) group drumming, and (4) group processing/check-out, described in Figure 1. Group discussion occurs continuously throughout the session, commonly during the time between the different interventions, to process the experiences before transitioning to the next. It takes approximately 90 min to facilitate the protocol from inception to completion.

Figure 1.

Components of the introduction to music therapy protocol.

Component 1: Rapport Building and Group Introductions/Check-in (approx. 20 min)

The session begins with a brief description of music therapy, its military roots, and an overview of how it is integrated into the clinical model of care. Figure 2 shows a handout that is distributed at the outset of session, which includes recommended resources such as a list of no-cost apps that enable the independent practice of skills learned in the session. Expectations of participation are then discussed, followed by a group check-in process during which service members are invited to share music-related information with the group. This may include: current uses of music; preferred music; most memorable concert experiences; history of formal/informal music training; music aspirations; and/or general life experiences. Through this sharing, service members can learn more about the values, attitudes, and previous experiences of other group members and discover commonalities amongst peers (James & Freed, 1989; Plach, 1980). This plays an important role in building a sense of camaraderie and group cohesion. Camaraderie is critical for service members, and they come to associate it with well-being and survival during military service. For example, unit cohesion during deployment has been identified as a potential buffer of service members developing post-traumatic stress and depression (Armistead‐Jehle, Johnston, Wade, & Ecklund, 2011).

Figure 2.

Music therapy resource sheet.

The first portion of this protocol addresses several goal areas: First, to establish initial rapport between the music therapist and participants and support ongoing rapport-building between service members through information sharing; second, to activate memory recall and reminiscence through sharing musical histories and memories. This is based on associative mood and memory training (AMMT), an NMT technique in which music is used to retrieve long-term memory information as a pathway to activate the working memory (l’Etoile, 2014). Third, to initiate a connection to past or present musical experiences and promote insight and discussion about current relationships to music, which can provide innovative opportunities for further goal-setting. Introducing goals during this portion of the protocol contextualizes the music therapy experience for service members and provides them with opportunities to strategize how they can utilize music within the group session, in subsequent music therapy sessions, in their overall treatment process, and in general life.

Component 2: Intentional, Active Music Listening (approx. 25 min)

This component focuses on intentional and active music listening with diaphragmatic breathing techniques, grounding exercises, entrainment of physiological responses to music, and intentional listening for identification of sound preferences. Music-guided breath work, progressive muscle relaxation, and imagery have been shown to promote psychological and physiological relaxation (Pelletier, 2004). This is especially relevant to military populations because the percentage of anxiety disorder diagnoses among all active-duty service members increased from under 2% in 2005 to over 5% in 2016 (Deployment Health Clinical Center, 2017). Moreover, an important goal in the treatment of PTSD is to learn practical anxiety management strategies that service members can easily employ outside of sessions (van der Kolk, 2000).

Because many of the service members in treatment may have difficulty initially engaging in relaxation, guided relaxation precedes active listening/sound discrimination exercises. This allows service members the opportunity to achieve mental and physical states conducive to associating sounds with relaxation. First, service members are invited to get comfortable in their chairs or on the floor and close their eyes or soften their gaze. Next, the music therapist facilitates music-accompanied breathing and grounding exercises to promote awareness of respiration and other physiological sensations and responses in a supportive environment.

Because music therapists in IOP settings may not have the opportunity of multiple sessions to determine relaxation response to sound preference, a variety of instruments are played in succession. Each instrument is played for approximately 2–3 minutes with 10 s of transition time between sounds dedicated to refocusing on breath awareness. Service members are encouraged to actively listen, discern between the different instruments, and determine which sounds, if any, are beneficial in promoting relaxation tailored to their needs. Verbal discussion to process responses directly follows this exercise. This component provides service members with information regarding pleasant and unpleasant sounds that may soothe, stimulate, or trigger negative associations. Because TBI and PTSD may result in hypersensitivity and persistence of biological arousal in response to sound stimuli, including neutral sound stimuli, exercises in sound discrimination, and processing of somatic reactions to different types of sounds and music is relevant (Landon, Shepherd, Stuart, Theadom, & Freundlich, 2012; McCurry, Frueh, Chiu, & King-Casas, 2020).

Goals of the intentional and active music listening portion of the protocol include to: (1) induce a relaxation response through reinforcement of diaphragmatic breathing and physiological entrainment to music, (2) promote mind/body connection, (3) enhance emotional regulation through modulation of limbic and paralimbic brain structure activity (Koelsch, 2009), and (4) identify preferences and responses to specific sounds and music. Preference identification is helpful in understanding physiological sensitivity and/or psychological associations to sounds related to lived experiences.

Processing of relaxation and intentional listening is facilitated through group discussion following the music experiences. The therapist may invite participants to play the instruments introduced in the intervention. Examples of recommended instruments are the Reverie harp and HAPI drum, which are pre-tuned to pentatonic scales, making them “user-friendly.” Allowing time to play the instruments can help service members in processing their responses to the music and may enhance their connections to the instruments, sounds, and overall experience.

Component 3: Group Drumming (approx. 25 min)

Group drumming has been used in a music therapy context with active-duty soldiers to address service-related issues by helping them regain a sense of control and build group cohesion (Bensimon, Amir, & Wolf, 2008). The component introduces drumming to enhance group participation, reinforce intentional listening, promote relaxation through physical release of tension, and to initiate selective, divided, and alternating attention through NMT techniques (Thaut & Hoemberg, 2014). Service members are introduced to technical aspects of how to play various hand drums (e.g., djembe, tubano, bongo, cajon). Figure 3 shows fundamental drum rhythms, including the “heartbeat” and variations of the Afro-Caribbean rhythm, Nyabinghi (JAFSP, n.d.), that service members are instructed to play.

Figure 3.

Afro-Caribbean rhythm notation, Nyabinghi.

Group drumming is a platform that can be used to assess service members’ cognitive abilities to engage in varying levels of attention using the guiding principles of music attention control training (MACT). MACT includes both active musical exercises and listening tasks. Musical stimuli are composed of both structured material and improvisation exercises. Musical elements are organized to elicit different musical responses by engaging focused, sustained, selective, or divided attention (Hegde, 2014). Additionally, issues with attention and concentration are prevalent in service members with PTSD and TBI, significantly impact their ability for social engagement and, hence, their quality of life (van der Kolk, 2000).

To initiate sustained attention, which is to fully focus on a singular task, rhythms are first taught in isolation and in succession to the entire group. To facilitate divided attention, which is to track and respond to two or more auditory stimuli simultaneously, each rhythm is then assigned to one or two service members, and the rhythms are played over each other to motivate listening to how the parts layer together and align rhythmically. To increase task complexity, service members are instructed to attempt listening and hearing the different rhythms that other members are playing while they play their assigned rhythms. Lastly, to facilitate divided attention, which is to alternate between two or more auditory stimuli and follow each stimulus as it is presented, the service members are instructed to rotate rhythms that they are playing as facilitated by the music therapist. At this time, the music therapist may solo over the group, playing both on beat and integrating syncopated rhythms while the group is instructed to maintain their groove. Adding spontaneous drumming over the group’s established rhythms assesses the service members’ abilities to remain on the task when unanticipated environmental changes occur. Furthermore, it models percussive improvisation. Improvisation and soloing reinforce attention, group cohesion, and provide the opportunity for service members to demonstrate skills they have learned through creative expression.

During the drumming intervention, the music therapist may facilitate cueing using principles of music mnemonics training (MMT) though using verbal phrases that reinforce the rhythms (say-and-play) and employs the use of focal points (visual, auditory) to assist service members in achieving successful drumming experiences. MMT uses songs, rhymes, and music in general as a mnemonic device that stimulates the activation of information sequencing and organization. Music also adds meaning, pleasure, emotion, and motivation, which amplifies the cognitive processes of information learning, retention, and recall (Gardiner & Thaut, 2014).

Goals of the group drumming component include to: (1) facilitate varying attention levels, (2) increase tolerance of auditory stimulation, (3) encourage emotional expression through group participation, performance, and improvisation, (4) increase social engagement by creating music as a team, and (5) reinforce goals from previous interventions. Specifically, group cohesion, intentional listening, and relaxation through physiological activation and release (e.g., in components 1 and 2) are reinforced. Drumming experiences are processed through group discussion.

Component 4: Group Processing/Check-out (approx. 20 min)

The last portion of the protocol provides an opportunity for final processing and session closure. Service members are asked to reflect on the different musical experiences and share their overall thoughts. At this point in the process, the service members have gained an initial understanding of music therapy, may feel an increased sense of connectedness towards their peers, and may have experienced unity in working towards group goals. Service members are encouraged to provide verbal feedback about what they learned and identify skills or techniques helpful for self-management and inclusion into daily routines. Verbalizing one’s experiences of the interventions and recognizing new abilities may help promote knowledge transfer and coping strategies outside of the therapy session (James & Freed, 1989). In addition to verbal processing, generalization of skills can be reinforced in follow-up sessions and integrated into treatment plans.

Secondary Analysis of Service members’ Evaluations

At the end of the Introduction to Music Therapy group, service members are asked to complete an evaluation form as standard practice (see Supplementary Appendix, online). From 2016 to 2017, service members (n = 201) completed evaluation forms at the NICoE in Bethesda, MD. The Drexel University team members (J. B. and J. B.) conducted a secondary analysis after de-identified data were shared with them. WRNMMC IRB exempt was obtained prior to sharing the data. The purpose of the evaluation form is to gather information about (1) perceived benefits and usefulness of the different music therapy interventions and protocol components, (2) emotions accessed and expressed during the session, (3) somatic awareness during the session, (4) lessons learned from intentional listening and group drumming, and (5) desire for follow-up music therapy sessions.

Results

Table 1 presents the demographic characteristics and clinical information. The majority of the participants were White males who served in the Navy. The listed health outcomes are obtained as a standard practice from all service members who receive services at the NICoE. These are commonly implemented across military treatment facilities that include Creative Forces music therapy programs.

Table 1

Demographic and Clinical Characteristics of Study Participants

Characteristic	N (%)
Age (years), mean (SD)	38.89 (6.31)
Gender, male	198 (98.5)
Ethnicity
White	67 (33.3)
Black	2 (1.0)
Asian/Pacific Highlander	4 (2.0)
Other	3 (1.5)
Did not report	125 (62.2)
Branch
Navy	122 (60.7)
Army	60 (29.9)
Marines	13 (6.5)
Airforce	6 (30.0)
Post-traumatic stress (PCL-M), mean (SD)	43.93 (15.76)
Depression (PHQ9), mean (SD)	9.72 (5.57)
Generalized anxiety disorder (GAD7), mean (SD)	9.67 (5.68)
Subjective well-being (SWLS), mean (SD)	23.2 (6.83)

In response to how helpful the music therapy session was overall, 85.8% reported that the session was moderately to very helpful. Table 2 shows the service members’ feedback regarding the perceived helpfulness of the different music therapy experiences presented in the group protocol. Two questions on the evaluation form aimed to assess whether there was a shift in the degree to which service members were able to listen to other group members during group drumming. A larger number of service members reported being able to listen to others while drumming at the end of the drumming experience (44.6%), compared with the start of group drumming (32.5%). Some service members reported having to completely block out others, namely 5.6% at the start of the group drumming and 2.6% at the end of drumming. These data suggest an increase in service members’ ability to manage the increased complexity of auditory (sound, rhythm) processing during group drumming.

Table 2

Perceived Helpfulness of Music Therapy Experiences (Percentages)

Music therapy experience	Not helpful	Somewhat helpful	Moderately helpful	Very helpful
Intro to musical resources	2	15.7	32.3	50
Music-guided breathing	2.5	12.2	35	50.3
Listening to guitar	1.5	8.2	39	51.3
Listening to piano	1	10.5	34	54.5
Listening to Hapi drum	4.6	19.9	32.1	43.4
Listening to voice & guitar	1.5	8.1	32.3	58.1
Group drumming	7.2	10.3	23.6	59
Group discussion of music experiences	2.6	16.2	34	47.1

Another area of the post-group evaluation addresses emotional expression. A total of 87.8% of service members reported that they were able to express emotions through music experiences, including pleasure and enjoyment (67%), calm and peacefulness (41.4%), happiness (33%), and nostalgia and longing (11.5%). Other emotions (i.e., excitement, anger, irritation, frustration, sadness, anxiety, fear, shame, guilt, love, tenderness, boredom, indifference, loneliness, alienation, confidence, interest, expectancy) listed on the evaluation form were endorsed by a minimal number of service members (0–10%). A total of 35.9% of the service members reported that the emotions they expressed through music were related to general life experiences. For others, emotions were related to family (25.5%), friends (22.1%), and childhood (22.7%). A total of 17.3% of the respondents endorsed that the emotions expressed were related to their military service.

The music experiences evoked somatic responses for the majority of the service members (89.6%). The most frequently reported somatic responses indicated a decrease in physical tension (56.3%), heart rate (35.9%), and respiratory rate (25%). Far fewer service members reported that they experienced an increase in physiological responses during the music therapy session (i.e., heart rate: 16.9%, respiratory rate: 10.4%, tension: 9.9%, and sweating: 7.8%). A total of 11.1% of the service members reported that these somatic responses caused discomfort. Most respondents did not offer explanation for the presence of discomfort in the comment section, although some reported that it was due to changes in responses to different music therapy experiences (e.g., relaxation vs. group drumming).

When asked what skills they learned during the session, the majority of service members reported gaining skills in music listening for relaxation purposes (61.5%), creating music as a team (60%), and being able to listen to others while playing music (46%). A total of 30.5% said that they learned to use music to control their breathing as well as discriminate which sounds/music are pleasant/unpleasant to listen to (35.5%). Finally, 86.2% of service members requested follow-up music therapy in the form of individual sessions (28.9%), group sessions (15.4%), or both individual and group sessions (36.8%).

Music Therapists’ Feedback

In addition to examining service members’ evaluation of the group protocol, we felt it was important to seek feedback from board-certified music therapists who have facilitated the protocol and evaluation tool as a standard of care in both IOP and longitudinal program models. We interviewed three Creative Forces music therapists who have an average of four years of working with military populations at the following sites: Intrepid Spirit Centers (ISC) at Fort Belvoir, VA and Fort Hood, TX; the TBI Clinic at Joint Base Elmendorf-Richardson (JBER), AK; and the NICoE at WRNMMC in MD.¹ All interviews were transcribed and returned to the music therapists for content review. Once feedback was received from the therapists, the answers to the interview questions were summarized by a research assistant. The aggregated responses to each question were then compared across the three respondents and main ideas were distilled. Because only three music therapists were interviewed, no thematic analysis was conducted.

Group Protocol

The music therapists indicated that their groups typically consist of five service members and that referral systems to the music therapy group differ across sites. At the NICoE and ISC Fort Hood, every service member attends the group as part of standard treatment, whereas at ISC Fort Belvoir and JBER, referrals are made by providers, such as nurse practitioners, occupational therapists, or speech–language pathologists. The group is conducted once weekly at JBER and the NICoE, bimonthly at ISC Fort Belvoir, and twice every six weeks at ISC Fort Hood. All groups are 90-min long.

The music therapists reported that the group protocol helps them obtain information regarding musical histories and preferences, social, cognitive, and self-regulation capacities, and overall group dynamics. One music therapist shared,

As a facilitator, I learn about music history, individual relationships with music, past music experiences, sensitivities to certain auditory stimuli, characteristics of social engagement, and I get a sense of personal and emotional responses to experiencing and making music. Facilitating the group protocol allows me to check in on discomfort or somatic responses that service members may feel from different music listening and music-making experiences. I gain initial information about how to approach individual sessions based on responses to prompts and activities in the group.

Additionally, music therapists stated that the protocol enables them to assess emotional responses to the different interventions and comfort levels with relaxation and creative expression. Another music therapist shared,

Through facilitating this group protocol, I am able to learn about the relaxation methods that service members practiced previous to attending the group. Within the first few minutes of the intervention, I can assess their current anxiety level and how easy or hard it is for them to relax by observing their nonverbal cues. I evaluate their anxiety during breathing exercises and use the instrumentation as a timestamp to indicate when they are able to start engaging in the relaxation. We process their experiences after the exercise, at which time, service members often engage in self-realization on how effectively they work through their anxiety, and I am able to make recommendations for home practice.

Regarding addressing anxiety through creative expression, a music therapist added,

It allows service members the opportunity to confront anxiety they may have about displaying their abilities in front of others and often results in personal realizations of resilience and, ironically, feelings of safety due to “weathering the storm” of anxiety together amongst peers sharing similar feelings.

The music therapists, furthermore, shared that this protocol offers insight into service members’ strengths and areas of development primarily through observing individual and interpersonal nonverbal cues during the drumming experiences and post-processing. In addition to cognition and attention skills, the music therapists shared that drumming and processing also support other components of the protocol (e.g., rapport-building, entrainment). The expressive musical interactions reveal information about interpersonal communication and group roles. One of the music therapists stated,

I learn service members’ ability/inability to sustain attention during drumming and if they can appropriately participate with focused, divided, alternating attention, dexterity, and coordination. During processing, I observe and learn their comfort levels with creativity and improvisation as opposed to more structured facilitation. Since this group is used as an initial interaction, it provides a window of service members’ affect and ability to express. For example, some are naturally expressive and for others, that is harder. In IOP programming specifically, I observe group cohesion, which is vital to detect early.

One of the music therapists valued the drumming component, “The drumming experience itself is helpful because it directly integrates intellectual concepts with a hands-on introduction to group music-making. With more socially reserved groups, drumming facilitates interpersonal connection and communication.” The music therapist further stated the importance of processing the drumming intervention,

The processing and discussion is very helpful to me as facilitator, because it opens a conversation for themes of sense-making, connections, and provides a platform for patients to share “ah-hah” moments, both from the drumming exercises and from earlier parts of the session, which then integrate fully at the end of the session.

The music therapists collectively concurred that Component 1 is the least helpful part of the protocol in terms of assessment; however, they identified it as essential in creating the therapeutic space at the start of the session. It also provides the opportunity to present the bottom line up front (BLUF), a common term used in the military, of the session. Music therapists can use time during Component 1 to present the BLUF by informing the patients as to why music therapy is included as a standard of care in their treatment, presenting session purpose, and answering any questions that patients may have at the outset of group regarding experiences and expectations of the session. Music therapists expressed that they appreciate the sufficient clinical flexibility offered to the therapist in terms of how to introduce the session. One of the music therapists reflected,

I think that I perceive this as “less helpful” because I am giving information, rather than facilitating an intervention. However, this part is a necessary foundation for establishing the group and offers an entry point for service members to use music intentionally outside of sessions to support their treatment goals, through using apps, etc... What I like about this part is that it allows for flexibility in introducing the group. My introduction varies between the IOP and ongoing care because the usage and outcome of the group is different in each program. For example, in ongoing longitudinal programming, my introduction included various treatment paths (individual, group, or both) and in the IOP model, I introduce this group as the first of six groups that provides tools and skill-building, as part of an interdisciplinary program.

Some adaptations have been made at different sites including showing a YouTube video about music and neuroplasticity at the outset of session and adding a Blues songwriting exercise. A music therapist shared,

Time permitting, I add Blues songwriting at the end. I like doing this as part of the first session, as it provides service members a chance to explain what they are feeling, what they have experienced in the session, their overall rehabilitation process, or share other life experiences.

Other modifications of the protocol can include varying the instrumentation that music therapists play in Component 2.

Post-Session Evaluation

We were also interested in learning how the service members at different sites perceived the post-session evaluation form and how the music therapists applied the service members’ responses. Music therapist feedback indicated that the evaluations are well-received and self-explanatory for the service members across sites. One music therapist shared an observation regarding incongruence between self-reported and presenting behaviors in the session, which may suggest a potential underreporting of challenges or difficulties:

I pay close attention to the discrepancy of how service members present and disclose in the group versus what they report on the form. That usually informs me about their level of self-awareness and also if they are under/over reporting or trying not to demonstrate challenges or difficulties.

Each of the music therapists stated that they use clinical observations coupled with service members’ evaluation responses to inform further treatment planning. Music therapists at JBER and the NICoE do this individually, while the interdisciplinary teams at ISCs Fort Hood and ISC Fort Belvoir collaborate on treatment planning for service members in IOP and longitudinal care programs. All of the music therapists reported uploading the evaluation information into the medical record by transferring information from the evaluation tool into a standardized note template that is input into the Armed Forces Health Longitudinal Technology Application (AHLTA)—the global electronic health records system used by the DoD. Additionally, the entire evaluation form can be scanned and added to AHLTA.

Discussion

This article presents an Introduction to Music Therapy group protocol and outcomes from a post-session evaluation completed by 201 active-duty service members. The session protocol is intended as a prefatory group session with 5–8 service members. The purpose of this session is to familiarize service members to various music therapy experiences. It also functions as an initial assessment of service members’ responses to receptive and interactive music experiences, offers information about the role of music therapy in interdisciplinary care, and indicates how to intentionally incorporate music into daily routines for specific results. A comprehensive review of the current literature suggests that publication of a group protocol and associated program evaluation data is the first of its kind, pertaining to music therapy with military populations in the US. This emphasizes the importance of publishing protocols and sharing service members’ music therapy treatment experiences, whether through the use of program evaluation, as reported in this article, or interviews with patients following music therapy.

Post-session evaluation data from a large sample of service members (n = 201) who received music therapy treatment at the NICoE were gathered. The results indicate that the majority of service members perceived the overall group music therapy session as moderately to very helpful. At the end of this introductory group, close to 90% of service members requested follow-up music therapy sessions. This suggests that the session protocol meets an important goal, namely helping service members understand the potential benefits of music therapy in their overall rehabilitation processes and general life experiences.

The evaluation data indicated that the group session helped to enhance awareness of service members’ somatic responses to the music. Enhanced awareness of bodily arousal in response to sound stimuli is an important aspect in the treatment of TBI and PTSD. The role of music therapy in enhancing somatic awareness has been reported in prior studies with other populations (Bradt, Norris, Shim, Gerrity, & Graceley, 2016; Bradt et al., 2015). In addition, most service members reported that they were able to express various emotions through the music experiences, which implies the emotional benefits of the music therapy session. This is critical because the majority of the service members included in this sample experienced moderate to severe PTSD. Greater PTSD severity has been found to be associated with increased difficulty in emotional regulation, likely due to changes in brain areas involved with emotional regulation secondary to trauma exposure (van der Kolk, 2000). Issues with emotional regulation, in turn, significantly impact social well-being and quality of life (Bonn‐Miller, Vujanovic, Boden, & Gross, 2011). Further, findings from the Introduction to Music Therapy group session post-evaluation indicated that 61.5% of respondents reported gaining skills in using music listening for relaxation. A large percentage of service members in our sample had a diagnosis of generalized anxiety disorder.

Our findings appear to align with studies that have shown that music therapy may be a useful tool to reduce stress responses and improve functioning among individuals with trauma exposure and PTSD (Blanaru et al., 2012). Theoretically-informed assessment and music therapy models are used as a tool for addressing symptoms of PTSD in regard to social, cognitive, and neurobiological mechanisms (e.g., community building, emotion regulation, increased pleasure, anxiety reduction) that promote music therapy’s efficacy as an adjunctive treatment for individuals with posttraumatic stress (Landis-Shack, Heinz, & Bonn-Miller, 2017).

Overall, service members experienced emotional expression as well as gained an enhanced awareness of how in-the-moment somatic responses play an important role in restoring or improving one’s ability for emotional and physiological regulation (Cameron & Overall, 2018; Moore, 2013). Most service members shared on the evaluation form that they were able to express and/or experience feelings of happiness, pleasure, calm, and peacefulness through the music therapy interventions where few endorsed emotions on the other end of the emotional spectrum, such as anger, frustration, fear, and loneliness. This is not surprising given that this was the first music therapy session and one of the first group sessions with fellow service members, thus trusted relationships are still developing. Moreover, the music experiences in the protocol are structured specifically to optimize feelings of safety and reduce perceptions of threat due to emotional risk-taking. In their study on the impact of group drumming with patients with persistent PTSD, Carr et al. (2012) assessed participants’ symptoms pre- and post-treatment using the Impact of Events Scale-Revised and Beck Depression Inventory II. In addition, they analyzed exit interview data and found that the group music therapy session helped to establish safety and trust, promoted emotional identification and expression, and enhanced capacity to tolerate particular sound qualities of instruments. These findings are congruent with the findings of our study. An advantage to the Carr et al. (2012) study is that there was a span of 10 sessions over which they were able to engender safe space wherein camaraderie, emotional expression, and trusted relationships could be gradually established and built upon over time. The protocol presented in this article occurred as a one-time session, demanding more immediate cohesion to optimize benefit.

In terms of somatic responses, most service members reported downregulation of physical and physiological responses (i.e., reduced physical tension, heart rate, and respiratory rate) during the music therapy session. Arnsten, Rasking, Taylor, and Connor (2015) found that uncontrollable stress and difficulties with emotional regulation are associated with impairments in working memory in Special Forces soldiers under conditions of stress exposure. Therefore, the ability to regulate physiological function in response to music may be a powerful tool for service members. Through technological advancement, music is readily accessible (e.g., on mobile devices), and service members with PTSD and anxiety disorders can work with music therapists to identify music to use during moments of increased stress or in situations that present the potential of emotional triggers. Similar to this study’s findings in which 87.8% of the participants reported an increase in emotional expression, somatic awareness, and capacity to manage complex auditory (sound, rhythm) stimuli, a study in Australia investigated music listening with military-connected participants (n = 205). They found that music listening shows promise as a self-management tool to support emotional and cognitive function (Zoteyeva et al., 2016). Study findings indicated that veterans engaged with music “more frequently each day than any other reported leisure activity, with 28.8% of the sample reporting listening to music several times a day” (p. 312). Additionally, they found that music listening is a helpful mechanism in mitigating mental and emotional problems and promoting post-traumatic growth.

In addition to obtaining feedback from service members who participated in music therapy sessions, it was important to obtain feedback from music therapists who facilitated the protocol across sites before disseminating the protocol. The music therapists interviewed for this article shared lessons learned from facilitating the protocol and cited which parts were most/least helpful and why. Music therapist feedback validated that the group protocol can be successfully implemented in both IOP and longitudinal treatment programs. Music therapists indicated that the group protocol is a helpful initial experience for service members to familiarize to music therapy, and for music therapists to learn about their patients’ specific needs, both individually and in a group context.

The music therapists also recommended protocol adaptations that they implemented to help meet specific patient needs or program model demands, such as adding an informative video at the start of session or facilitating a brief songwriting and music-making experience at the end of session. Additional elements may be implemented if time permits. However, therapists should allot sufficient time at the end of the session prioritized for group discussion, final processing, and completion of the evaluation form.

A few limitations of this study need to be noted. The post-session evaluations were obtained from one site, limiting service members’ feedback to the protocol being implemented solely by one music therapist. Since session evaluation data were obtained by the music therapist who implemented the session, social desirability is likely. Furthermore, the majority of the participants who participated in the Introduction to Music Therapy protocol and who completed the post-session evaluations were White males in the Navy; this group protocol may be experienced differently by other genders or ethnicities. Follow-up interviews with service members would have provided additional valuable data.

We invite music therapists who work with service members or veterans to use this protocol and make necessary adaptations as needed for their patient population and facility. We encourage the music therapy community to share music therapy protocols for which a sufficient amount of user feedback has been gathered. To date, very few music therapy protocols have been published, and according to MTR2025, sharing protocols can play an important role in advancing the clinical practice of music therapy. We acknowledge that the protocol presented here is not appropriate for efficacy testing as it is meant to introduce service members to music therapy experiences. Therefore, service members and music therapist feedback were sufficient to validate the protocol’s utility.

Conflicts of interest: The authors have no declaration of interest. The views expressed in this article are those of the author and do not reflect the official policy of the Department of the Army/Navy/Air Force, Department of Defense, or U.S. Government. The identification of specific products, scientific instrumentation, organizations, individuals, or compositions is considered an integral part of the research endeavor and does not constitute an endorsement or implied endorsement on the part of the author, DoD, or any component agency.

We would like to acknowledge the men and women who bravely serve their country in the U.S. Armed Forces. The authors would also like to recognize the leadership, providers, and staff at the NICoE, Intrepid Spirit Centers, military treatment facilities, and VA hospitals. Many thanks to Hannah Bronson, MT-BC, Nathaniel McLaughlan, MA, MT-BC, and Danielle Vetro-Kalseth, MM, MT-BC, for providing insight and expertise in utilizing this protocol and evaluation. Special recognition to Julie Garrison, MA, MT-BC, Kalli Pelaccio, MT-BC, and Abigail Palmer, MT-BC for their facilitation of music therapy groups at the NICoE. This work was supported by the Creative Forces®: NEA Military Healing Arts Network, an initiative of the National Endowment for the Arts (NEA) in partnership with the U.S. Departments of Defense and Veterans Affairs and the state and local arts agencies. This initiative serves the special needs of military patients and veterans who have been diagnosed with traumatic brain injury and psychological health conditions, as well as their families and caregivers. Administrative support for the initiative is provided by Americans for the Arts.

Footnotes

1

One music therapist worked at two sites; hence, three music therapists represent four sites in this section.