Preparing to work in the field of trauma as an MT-BC

Some more of my writing.   Instead of a book — I’m just pouring out onto the blogosphere.

 

In preparing to work in the field of trauma and abuse, the main tasks are to:  establish where the evidence base is for designing treatment, and narrow down how to specifically utilize music prescriptively.  Current literature and research points to the trauma-focused therapies as the industry standard for treatment.   The way that a traumatized person responds to life as opposed to someone who has not been traumatized is very different.  Trauma has such an all encompassing effect on a person and their family involving the family system, one’s perception of the world, spirituality, social life, sexual development and so on.   So it makes sense that when treating someone specifically for recovery from trauma, you would look to any number of trauma-focused literature to help conceptualize treatment for your client.

 

 

To start with, lets take a look at how trauma effects the brain. Then let’s take into account how music effects the brain and then we can combine the two inquiries to determine how music can affect a traumatized brain.  The work of Dr. Bruce Perry  is a helpful resource to begin with.  The current research in trauma suggests that trauma affects the brain concurrent with the developmental stage in which the abuse or trauma occurs.  In particular, research suggests that the amygdala, hippocampus and prefrontal cortex are specifically involved .  What happens in a child survivor of trauma can manifest as a maladaptive reaction to everyday occurrences or minor stressors such as:  losing a shoe, being denied a snack or having a bad experience on the playground with a peer.  In response to a minor stressor, for example, the brain activates a stress response, completely bypassing the executive centers of the pre-frontal cortex. Cortisol is released and the child experiences a fight or flight response.   Unable to process the minor stressors through problem solving and reasoning, the child may find them selves later trying to explain to peers, teachers or family why they reacted in such a way (for example with an impulsive decision, aggressive behaviors or self harm).

 

We know that music effects the brain in a myriad of ways.   As a music therapist or student of music therapy you are well aware of the foundational and current literature about how music effects the brain.   Some interesting research that I think is helpful in terms of looking at trauma would be to examine some recent research that targets how music helps with regulation.   I will incorporate that information a little later in this chapter when I tie in how music can help the traumatized brain.

 

Before we look at how a music therapist can use music to help a client with abuse related trauma, lets take a quick look at the current body of literature for trauma.   The current industry standard for treating abuse is defined as any one of the “trauma- focused” therapeutic approaches.   It is a good idea to get familiar with some of these before moving towards looking at how to apply music therapy to treat trauma. Two  different therapeutic approaches that stand out among the various available types of treatment for abuse in the current literature are:  are Trauma Focused Cognitive Behavioral Therapy (TF-CBT) and the Chadwick Center’s Trauma Assessment Pathway (TAPChadwick).   I would like to share a little information about these approaches in particular because I feel that they are helpful when looking at adapting music therapy interventions for this population.

 

First, the current literature in the field of child abuse points to the use of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) as the primary and most evidence-based method of treatment for survivors of child sexual abuse.  Widely adopted by licensed professional counselors, this method has been proven effective for the treatment of trauma.   The music therapist can work adaptively within this model.

 

Trauma Focused Cognitive Behavioral Therapy, or TF-CBT follows a specific protocol.   The TF-CBT (typically used with clients aged 3-18 years of age) model contains the following steps and you can use the word “PRACTICE” to remember the steps (taken from Child Welfare Information Gateway http://www.childwelfare.gov/pubs/trauma):  Psychoeducation and parenting skills (including teaching the child about the trauma and the associated emotional and behavioral reactions while providing parenting skills to parents or adult caregivers focusing on behavior management and effective communication), Relaxation (teaching relaxation skills including breathing techniques, progressive muscle relaxation and imagery), Affect Expression and Modulation (learning about feelings –how feelings are experienced and learning how to identify and express feelings, managing reminders of the trauma ) Cognitive coping and processing (learning the connection between feelings, thoughts and behaviors), Trauma narrative and processing (telling the story of the abuse in a literal or symbolic manner and the subsequent processing of the same), In vivo exposure (Mastery of trauma reminders or triggers, coping with memories of the abuse as they are experienced in current daily life), Conjoint parent child sessions, and Enhancing future safety and development (anti-victimization skills, healthy relationship skills, healthy sexuality, managing future stressors and ongoing coping skills).

 

 

In another frequently used model, the Trauma Assessment Pathway, the Trauma Wheel (TAP, Chadwick Center for Families) provides a framework for the primary mechanisms of treatment.   The trauma wheel contains the following sections: Psycho-education and Skill building, Addressing Maladaptive Cognitions, Affect Regulation, Trauma integration, and System Dynamics with overall consideration for cultural norms, developmental level and therapist/client rapport.

 

Keeping up with current or new literature in the field of child traumatic stress can be a challenge because it is a rapidly growing field of treatment and research.  I have also found it helpful to sifting through various interventions used by other treatment modalities to see about how to adapt the ideas to music therapy.   In addition, I occasionally come across other discliplines using music in therapy (song lyrics, listening to music, creating “songs”) and it is helpful to back to foundational knowledge of music therapy to determine the effectiveness of the intervention for a client (checking for contraindications, making adaptations, etc).

So, now, let’s take a quick look and summarize how can a music therapist help someone recover from abuse-related trauma? It’s up to the MT to design treatment within the scope.  Beginning with the obvious, music therapy is a great way to develop the client-therapist relationship.  Music Therapy is a tool for affect regulation https://academic.oup.com/jmt/article-abstract/50/3/198/1007477?rss=1  and Kimberly Sena Moore has some wonderful research in this arena.   http://www.musictherapymaven.com/my-publications/

 

Music-assisted relaxation is a wonderful way to help clients work on #3 and #4. Songwriting can be used to deal with maladaptive cognitions.   Songwriting can also be used to create a format for memorizing anti-victimization skills.    To work on the trauma narrative or integration the MT can utilize improvisational music therapy, music and writing, music and movement or music and other arts.   Traumatic memories and feelings don’t connote actually recounting every detail of the trauma verbatim.    Often it may be something that the client can easily remember but not necessarily something they can translate into words that come from their mouth.  As a matter of fact, that almost always is something that the child takes care of in the forensic interview and probably won’t have to revisit completely unless there is a court date or trial in which the client or child is asked to testify as to details of the abuse (preparing for court experiences like this is another aspect of treatment to discuss).  Rather, I would suggest that you think of this  in terms of “trauma integration” and look at is as the client expressing the feelings related to the abuse, retelling the story in different times during therapy using a variety of mediums, talking about feelings in a before and after context, and so forth. The process of trauma integration because what is considered to be a “gradual exposure”. It is not always necessary or therapeutic for a client to tell the exact details of the abuse and often times it may not be the most difficult aspect of the abuse recovery process.  It may be completely unnecessary for the client.  Often times I think the therapists and adults involved with the client are the ones who need to process the child’s abuse because we can do that as observers and we probably have more insight and need to process this with another helpful person.  A lot of times, in my experience, the hardest parts of recovering from abuse for a client are more about the changes in the family or social support system since the abuse happened, because when a child is abused it is usually by a known person and that relationship is now severed and the family system or social support is now damaged.   As a result, people choose sides and those aspects of recovery create a long hard road for the client to navigate.

 

 

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MT Building Rapport . Foundations in MT with the traumatized client

I was thinking of writing a book.    I wrote 12 chapters a couple years ago.   I stopped, I reviewed it, I wanted to rework it…..I needed to revise as research and modalities continued to change and evolve.   I realized that things are changing so fast in this field so ….  I have decided to release my thoughts into the blogosphere instead.    ……

 

There are many decisions to make when providing treatment for someone recovering from child abuse.   I will introduce a few tools that I have found helpful in developing a plan for treatment.  The latest research keeps changing and the field is a constantly moving target to find the best mode of treatment.   Still, as a music therapist, return to the foundations of the profession.   Things that remain the same:   the effect of music and rhythm on the brain and state/trait anxiety, how music effects emotions, the effect of music on mood, referential music, preferences of the client, the benefit of music involvement in a social group, the benefit of music for an individual, the contraindications of music and sound stimulation in certain instances.   The improvisation model of Music Therapy and the 64 clinical techniques (Bruscia, 1987) applied in various settings.     The foundations of music therapy and the training a music therapist receives is valuable and relevant.  Various models  have entered the field of trauma as “new” and left as new models come in to better the old ones.   I currently love using the TAP model developed by the Chadwick Center in San Diego (2009) as my compass. It’s not the latest but it is proving to be a good clinical model in my work and fits nicely still with the models available and with Music Therapy and our scope of practice.  In short, or first, I like to envision music therapy treatment for this population in my mind in this order: building rapport, client safety and containment, developing coping skills, processing, mastery.  There are many ways to conceptualize this in practice.     I have noticed that  survivors of child abuse  perceive what happened to them very differently at different developmental stages so these steps are repeated each time a survivor returns to therapy.   It is common to see a child at 8, and again at 12, and then at 16 years of age and so on.  This is congruent with what the literature reveals as well.  I’ve had clients return at different ages and they don’t seem to have vivid memories of the therapy process itself but the skills seem to hold over time. The need to build upon the skills, however,  in an age appropriate way is still evident.

The first step for treatment in this population is to meet your client “where they are” and build rapport.       Clearly, this is the same for every population.  Improvisational skills and techniques can be invaluable tools at this point because it provides for a nice “agility” within the music therapist skill set in navigating client needs during a session. Building rapport can take a variety of forms and it is basically the stage in therapy where you want to try to connect with your client so that  later you can move into the work of giving them the skills they need to heal and navigate their world.   One of the nice benefits of music therapy is that basic rhythmic interventions such as drumming or simple music making can be designed to help build rapport with your client while working on brain stem modulating goals to assist with client stabilization and sense of safety or containment.  A stable brain is a safe brain and a stable brain contains the trauma.  So building rapport can take on more than one goal and count towards treatment of neurologic or physiologic symptoms in addition to establishing the client/therapist relationship.   The beauty of what the music therapist can do in a session for the trauma client is amazing and complex.

What the current brain based research indicates to us  is that brain stem-modulating interventions are very successful in dealing with the basic problems of abuse related trauma and dysregulation.  Dealing with triggers, grief, false guilt, etc. can be enormously helpful but if the client leaves the session and has no way to turn off the autonomic nervous system or cope with any feelings that come up during the week, then you may find that the therapy takes two steps forward and three steps back.  So don’t get ahead of yourself or the client.   It is OK to stay in this stage for a while.  Maybe that is as far as you can get with your client.   That’s ok .  If your client doesn’t want to process it may be because they don’t need to or are not ready.   The agenda of the therapist or the adults in the child’s life may observe a need but the child may not be ready.  (In turn, as a clinician, if the clinician doesn’t feel ready to process, then the child’s need to process may not be met and should not be met until the therapist feels equipped — that’s another issue but as therapists we know how to deal with how to educate and equip ourselves right?)  It makes sense that the music therapist would work from the “ground up” so to speak and start with experiences and interventions that target these basic brainstem functions as the therapy begins.   Simple interventions like drumming and basic music and movement can activate and regulate through providing repetitive experiences while building non-threatening rapport.  Bruce Perry suggests that rhythmic activity be set at 80 beats per minute, or subrhythms of 40 or 60, to match the primary maternal heart rate in utero (Perry 2006) .

There is a lot more to add and discuss.   This is a small excerpt of some things I have been writing.   I wanted to share them with you.

 

Bruscia, K, (1987).  Improvisational Models of Music Therapy.  Springfield Illinois: Charles C. Thomas Publishers.

Chadwick Center for Children and Families. (2009). Assessment-Based Treatment for Traumatized Children: A Trauma Assessment Pathway (TAP). San Diego, CA: Author.  Copyright 2009 by the Chadwick Center for Children and Families, Rady Children’s Hospital and Health Center, San Diego. All Rights Reserved.

Perry, Bruce D. (2006). Applying Principles of Neurodevelopment to Clinical Work with Maltreated and Traumatized Children.  The neurosequential Model of Therapeutics, Chapter 3, 27-51.  Ripreinted from Working with Traumatized Youth in Child Welfare edited by Nancy Boyd Webb.  Copyright 2006 by the Guildrod Press 72 Spring Street, New York, NY 10012.

 

“Improving Health through Trauma Informed Care: A Medical Perspective “

I just got back from presenting at this really cool one day conference in Houston, Texas.   Presenters included: Marisa B. Nowitz, MSW, LCSW-S of the Texas Trauma and Grief Center (TAG) at Texas Children’s Hospital, Sandra Lopez LCSW, ACSW, DCSE Diplomate in Social work and Retired Professor University of Houston, and Nicole Porter Wilcox, MA, ATR-BC, LPC, LCAT,  Creative Director at Emerald Sketch ART.   I did a short training on trauma informed care with music therapy and then led the group into some interactive work to apply to scenarios that an MT may find in their work.  It was an exciting day and so refreshing to spend the day with such passionate music therapists and other creative arts professionals and advocates.   Really amazing.

 

32nd International Symposium on Child Abuse

I had the pleasure of presenting a workshop at the recent 32nd International Symposium on Child Abuse in Huntsville, Alabama with my colleague Angi Gibson, LPC.   The topic was generated after I noticed that therapists from a variety of different disciplines utilize popular music as a listening tool in their therapy sessions.   I presented from the music therapy perspective on the use of popular music for meeting the adolescent client where they are “at”, listening, lyric analysis and the possible contraindications that one might encounter when using music in the course of trauma focused therapy for child abuse.   It was so much fun to hear how other professionals in the counseling, social work and child protective services world utilize popular music with their clients.  I was happy to share  the time with such a wonderful group of helping professionals.   The room was packed with many eager to make more connections with their clients and children in their care.   Amazing group of people and wonderful experience.

Webinar available from Mindstorm Monday

The wonderful team at http://www.musictherapyed.com/blog/  invited me to do a webinar about my work.   It is available online here:

http://www.musictherapyed.com/mindstorm-monday/

Tania Cordobes MM Feb 1

 

Best Practices for Music Therapy with Child Trauma Victims

Tania Cordobes, MMT, MT-BC shares her expertise in working with children who have experienced trauma, and what YOU can do to best support your clients and their family members within this population.
Air date: February 1, 2016

 

 

The Ocean Drum, Anxiety, and Trauma

ocean imageOne of the most important skills you can teach someone who has suffered trauma (abuse)  is the ability to regulate affect.   The same goes for a non offending family member or parent.  One of the tools that I like to use in the ocean drum.   I like to use the Remo brand ocean drums.   I have a large one and a smaller one.  I think one of the first things some therapists might lean towards when dealing with controlling affect or mood is the use of soothing music or nature sounds to help a client relax or regulate.  One of the caveats with this is that if the client has any anxiety that tends towards the “free floating” kind, the loose mental state of music that is considered in the “relaxation” genre may actually feel unsafe and ungrounding.   The use of the ocean drum is a great solution for that issue.   The client will still get to experience the sounds of the ocean with this very important added element :  control.   The client will be creating their own sounds using the ocean drum which provides the ability to maintain physical control over the drum itself thus giving the client control over the sound.   The fact that the client is using their arms and hands to manipulate the drums while they are listening to the sound they are creating is both relaxing and grounding at the same time.   I really prefer this method for relaxation for clients who are dealing with anxiety as opposed to the non-participative relaxation to music.

“We Are Music Therapists” new blog post by guest Judy Simpson, MT-BC

Please enjoy this post by my guest Judy Simpson, MT-BC

“We are…MUSIC THERAPISTS!”
Judy Simpson, MT-BC
Director of Government Relations, American Music Therapy Association
When I started my career as a music therapist in 1983, it was not uncommon for me to describe my profession by comparing it to other professions which were more well-known. If people gave me a puzzled look after I proudly stated, “I use music to change behaviors,” I would add, “Music therapy is like physical therapy and occupational therapy, but we use music as the tool to help our patients.” Over the years as I gained more knowledge and experience, I obviously made changes and improvements to my response when asked, “What is music therapy?” My enhanced explanations took into consideration not only the audience but also growth of the profession and progress made in a variety of research and clinical practice areas.
The best revisions to my description of music therapy, however, have grown out of government relations and advocacy work. The need to clearly define the profession for state legislators and state agency officials as part of the AMTA and CBMT State Recognition Operational Plan (http://www.musictherapy.org/policy/stateadvocacy/) has forced a serious review of the language we use to describe music therapy. The process of seeking legislative and regulatory recognition of the profession and national credential provides an exceptional opportunity to finally be specific about who we are and what we do as music therapists.
For far too long we have tried to fit music therapy into a pre-existing description of professions that address similar treatment needs. What we need to do is provide a clear, distinct, and very specific narrative of music therapy so that all stakeholders and decision-makers “get it.” Included below are a few initial examples that support our efforts in defining music therapy separate from our peers that work in other healthcare and education professions.
• Music therapist’s qualifications are unique due to the requirements to be a professionally trained musician in addition to training and clinical experience in practical applications of biology, anatomy, psychology, and the social and behavioral sciences.

• Music therapists actively create, apply, and manipulate various music elements through live, improvised, adapted, individualized, or recorded music to address physical, emotional, cognitive, and social needs of individuals of all ages.

• Music therapists structure the use of both instrumental and vocal music strategies to facilitate change and to assist clients achieve functional outcomes related to health and education needs.

• In contrast, when OTs, Audiologists, and SLPs report using music as a part of treatment, it involves specific, isolated techniques within a pre-determined protocol, using one pre-arranged aspect of music to address specific and limited issues. This differs from music therapists’ qualifications to provide interventions that utilize all music elements in real-time to address issues across multiple developmental domains concurrently.

As we “celebrate” 2014’s Social Media Advocacy Month (http://musictherapystaterecognition.blogspot.com), I invite you to join us in the acknowledgement of music therapy as a unique profession. Focused on the ultimate goal of improved state recognition with increased awareness of benefits and increased access to services, we have an exciting adventure ahead of us. Please join us on this advocacy journey as we proudly declare, “We are Music Therapists!”

About the Author: Judy Simpson is the Director of Government Relations for the American Music Therapy Association (http://www.musictherapy.org). She can be reached at simpson@musictherapy.org