Music Therapy With Military Populations: A Scoping Review

Abstract

Music therapy treatment is increasingly being used to promote health, enhance quality of life, and improve functioning in military personnel, but evidence on the use of music interventions with military service members is still emerging. The purpose of this scoping review was to synthesize the available literature regarding music therapy treatment with military personnel by identifying the types of information available, key characteristics, and gaps in the knowledge base. The review was completed using the methodological framework proposed by Arksey and O’Malley. A total of 27 publications met the criteria for review. The results included anecdotal reports, white papers/ briefs, case studies, historical reviews, clinical program descriptions, and research studies. Both active duty and veteran service members were represented in the literature, and post-traumatic stress disorder and traumatic brain injury were the most commonly listed conditions among those served. Music therapy services were offered in both group and individual formats, and drumming was the most common music intervention cited. Most publications accurately represented music therapy, and the historical reviews highlighted the connection between the development of the field of music therapy and the use of music with military personnel. Several gaps were identified, including a lack of specificity in reporting, low levels of evidence, and limited inclusion of women service members.

In the United States, musicians first began performing for injured soldiers during the American Civil War (Sullivan, 2007). This tradition continued throughout World Wars I and II, and music served to entertain, motivate, stimulate, and build morale among service members (Robb, 1999; Rorke, 1996; Taylor, 1981). By the end of World War II, community musicians were performing for thousands of veterans suffering war-related physical and emotional trauma, and wounded soldiers’ consistent and positive responses to music led the military to examine the usefulness of therapeutic applications of music for wounded and disabled veterans (American Music Therapy Association, 2014; Taylor, 1981). In 1945, the military officially integrated music into its reconditioning program, outlining orders for the use of music with military personnel and thereby marking the beginnings of the modern music therapy profession (Rorke, 1996; Sullivan, 2007).

During the mid and late 1940s, the field of music therapy continued to advance as both advocacy for and research on the effectiveness of music therapy grew (American Music Therapy Association, 2014; Robb, 1999; Rorke, 1996; Sullivan, 2007). This growth led to demand for specialized training for musicians who wanted to work in medical settings, prompting the establishment of the first music therapy academic training programs (American Music Therapy Association, 2014, 2018a). The development of college degree programs was subsequently followed by the creation of the National Association for Music Therapy in 1950 (American Music Therapy Association, 2014, 2018a; Davis, 1993; Robb, 1999; Sullivan, 2007). This organization was the first body to promote music therapy standards, certification, and research, as well as the exchange and evaluation of information among music therapists (Rorke, 1996).

Today, music therapy is defined as the “clinical, evidenced-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program” (American Music Therapy Association, 2018a), and over 8,000 music therapist practice in the United States (American Music Therapy Association, 2018b). Music therapists who work with military populations provide services to military personnel, their families, service members in transition, and veterans. Some music therapists work directly within Veterans Administration facilities, while others work on military bases with active duty military personnel and their families (American Music Therapy Association, 2014). New initiatives like Creative Forces, the National Endowment for the Arts’ (NEA) Military Healing Arts Network (NEA, n.d.) have developed, expanding music therapy services to focus on the special needs of military personnel who have been diagnosed with traumatic brain injury (TBI) and psychological conditions like post-traumatic stress disorder (PTSD). An initiative of the National Endowment for the Arts, 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.

Music therapists who work with service members use evidenced-based music interventions to address physical, mental, and/or emotional needs. Music therapy can serve as a targeted, stand-alone treatment as well as co-treatment with other disciplines, addressing individualized needs in speech and language, cognition, motor coordination, social integration and engagement, psychological health, and spousal/family support (Bronson, Vaudreuil, & Bradt, 2018). Music therapy services span the continuum of care (American Music Therapy Association, 2014), are provided in a wide range of settings, and include diverse interventions like songwriting, lyric analysis, and group music making, among others (American Music Therapy Association, 2014; Bronson et al., 2018). Current research on music therapy with military populations is growing, but more information is needed to inform practice in a field.

Methods

Scoping Reviews

Scoping reviews are a type of exploratory literature review based on a framework for synthesizing both published and gray literature (Peterson, Pearce, Ferguson, & Langford, 2016). The methodology for a scoping review is similar to other systematic review formats, and like traditional systematic reviews, scoping reviews start with a primary research question. However, these questions are broad in scope and exploratory in nature. Protocols for a scoping review are developed a priori, and again, like traditional systematic reviews, inclusion and exclusion criteria and procedures are predefined (Peterson et al., 2016). However, deviations are allowable due to the iterative nature of the process (Peters, Godfrey, McInerney, Parker, & Baldini Soares, 2015).

The primary intent of a scoping review is to identify gaps in the research knowledge base and report on the types of evidence that inform practice in a field. Scoping reviews do not include a formal assessment of methodological quality (Joanna Briggs Institute, 2015), nor do they contain much statistical information (Peterson et al., 2016). Instead, results are synthesized and presented narratively. Scoping reviews allow researchers to identify the extent of research available on a topic as well as how the research has been conducted, and therefore they can be particularly useful when evidence related to a selected topic is still emerging (Joanna Briggs Institute, 2015; Whittemore, Chao, Jang, Minges, & Park, 2014).

Given the emerging evidence on the use of music interventions with military populations, we determined that a scoping review would be the most appropriate approach to identify how music has been used with military populations, clarify key concepts, and report on the evidence that informs music therapy practice with military populations. We conducted this review using the methodological framework proposed by Arksey and O’Malley (2005); this framework contains six stages, with the sixth being optional. We chose to incorporate the first five stages which included: (1) Identifying research questions, (2) Identifying relevant studies, (3) Selecting studies, (4) Charting data, and (5) Collating, summarizing, and reporting results.

Stage 1: Identifying the Research Question.

Our aim was to synthesize the available information regarding the use of music therapy to promote health, enhance quality of life, and improve functioning in military personnel. More specifically, we sought to (a) identify the types of information available, (b) identify key music therapy treatment characteristics, and (c) identify gaps in the knowledge base. Our intent was to explore the following research questions:

• What types of evidence exist regarding music therapy treatment with military service members?

• What are the key characteristics of military service members who participate in music therapy interventions?

• What are the key characteristics of music therapy treatment with military service members?

• What are the key characteristics of the music interventions being used with military service members?

• What are the gaps and limitations in the literature on music therapy treatment to promote health and improve functioning in military service members?

Stage 2: Identifying Relevant Studies.

To identify relevant studies, we developed key inclusion criteria based on the Population–Concept–Context (PCC) framework recommended by the Joanna Briggs Institute (Joanna Briggs Institute, 2015) (see Table 1 for criteria). We then developed a comprehensive search strategy based on the three-step approach recommended by Khalil and colleagues (2016). This approach includes a (1) limited search to test keywords using EBSCOHost, (2) comprehensive electronic database search using identified keywords (ProQuest, ProQuest Dissertations and theses Global, and PsychInfo), and an (3) analysis of reference lists from identified studies.

After keywords were tested, the comprehensive database search was conducted between January 1, 2018 and October 1, 2018. The search was updated between January 1 and April 1, 2019. Specific search terms used in the database search included “music” AND “military,” and filters were applied to retrieve publications in English between January 1988 and March 2019. Following the database search, reference lists from identified studies were analyzed and music therapy journals were searched because of their potential relevance to the topic. The journal search included the following journals: Approaches: An Interdisciplinary Journal of Music Therapy, Australian Journal of Music Therapy, Canadian Journal of Music Therapy, Journal of Music Therapy, Music Therapy Perspectives, Nordic Journal of Music Therapy, and Voices: A World Forum for Music Therapy. Three websites were also searched, including the Creative Forces: NEA Military Healing Arts Network website, the Americans for the Arts website, and the American Music Therapy Association website.

Stage 3: Study Selection.

Publication selection started by removing any duplicates found during the search. Titles and abstracts were then screened for relevance, and a list of potentially relevant publications was developed. Next, full text publications were assessed for eligibility and then reviewed by both researchers until inclusion agreement was reached. The publication selection process is described in Figure 1.

Stage 4: Charting the Data.

Selected documents were reviewed, and information was extracted and tabulated using a data extraction form created by the researchers. The following categories of information were extracted from each study: author, date, publication type, country, military personnel involved, diagnoses, provider, and intervention description.

Results

Publication Characteristics

A total of 27 publications met inclusion criteria. Of these publications, seven (25.93%) were research studies, six (22.22%) were historical reviews, seven (25.93%) were case studies, case reviews, or clinical program descriptions, two (7.41%) were anecdotal reports, two (7.41%) were status reports/white papers, two (7.41%) were theoretical frameworks paper, and one (3.70%) was a literature review. Papers were published between 1994 and 2019, with the majority written between 2008 and 2019. Twenty-three of the publications focused on military personnel in the United States, and all research studies have occurred since 2008. Research designs used included mixed methods (n = 2), single group, pretest/posttest design (n = 1), descriptive survey (n = 1), randomized controlled trial (n = 1), retrospective study (n = 1), and a feasibility study (n = 1). Music therapy was correctly identified in all publications but one, a publication by Powers, Heim, Grant, and Rollins (2012). The authors of this publication labeled their musical interactions as music therapy, but the use of music did not constitute music therapy as defined by the American Music Therapy Association (2018a) (see the literature review for the definition). Table 2 provides more detailed information on all publications included in this review.

Historical Publications

A variety of musical experiences and music interventions are represented in the publications included in this scoping review. The primary purpose of the historical documents was to provide descriptions of music entertainment and engagement (i.e., recreational and motivational) opportunities offered during World Wars I and II (Davis, 1993; Reschke-Hernandez, 2014; Robb, 1999; Rorke, 1996; Spencer, 2013; Sullivan, 2007). However, these publications also referenced some of the first uses of the term “music therapy” (Davis, 1993; Robb, 1999). Likewise, the historical reviews outlined early protocols developed by music therapy pioneers. This included guidance on the selection of musical elements like instruments, genres, and keys (Davis, 1993), training considerations like an emphasis on functional skills (Robb, 1999), specified interventions like mental imagery coupled with music (Davis, 1993), and interprofessional strategies like obtaining physician permission and building rapport with nurses (Davis, 1993). All the musical interactions in the historical reviews took place in military hospitals, and all highlighted positive responses to music among the military service members including increased engagement with live, familiar music (Reschke-Hernandez, 2014), responding to music when other stimuli failed, increased motivation to participate in treatment, and positive mood changes (Robb, 1999). Table 2 provides more detailed information on the publications included in this review.

Service Member Characteristics

Both active duty (n = 14) and veteran service members (n = 17) were represented in the publications included in this review. Individuals in the Reserves or National Guard were only mentioned in one publication (Gantt, Dadds, Burns, Glaser, & Moore, 2017). Information provided about service members’ military branch was limited, with only three articles providing a clear breakdown of the branch of service among participants (Bradt, Biondo, & Vaudreuil, 2019; Gantt et al., 2017; Vaudreuil, Bronson, & Bradt, 2019). The most common condition addressed in the publications was PTSD or shell shock (n = 21), and the second most common was TBI (n = 13). Other conditions addressed included moral injury (Gimpel, 2016, 2018), military sexual trauma (MST) (Story & Beck, 2017), stress (Americans for the Arts, 2013), and physical injuries (Steward, 2018; Vaudreuil, Avila, Bradt, & Pasquina, 2019), though these were not as common as PTSD or TBI. It is important to note that all publications related to TBI occurred after 2007 (i.e., 2013 and later), which is post-implementation of mandatory TBI screening for all veterans (Military.com, 2018). Male veterans were served most often, with only two publications specifically addressing the needs of female veterans (Story & Beck, 2017; Wellman & Pinkerton, 2015). See Tables 2 and 3 for additional information related to gender, race, status, and other factors.

Music Therapy Characteristics

A total of 14 publications included information regarding clinical music therapy services or music interventions to promote health, enhance quality of life, and improve functioning in military personnel. Of the 14 publications, 13 discussed services provided by music therapists, and 1 (Gantt et al., 2017) investigated a self-listening program in which there was no provider (service members implemented the listening program themselves). A music therapist was, however, involved in the development of the listening program. Music therapy was offered in both group (n = 10) and individual format (n = 11), and most music therapy interactions took place in facilities associated with the military, primarily in military hospitals or Veterans Affairs (VA) facilities (n = 8). Telehealth delivery of interventions was also discussed in one publication (Lightstone, Bailey, & Voros, 2015).

Active music making was cited in most of the clinical publications (n = 9), and the most common specific music intervention listed was drumming (n = 8). Other interventions discussed in the publications ranged from music listening (Bensimon, Amir, & Wolf, 2012), music-assisted relaxation (Garrison, 2016), and song share (Bronson et al., 2018), to therapeutic singing (Bronson et al., 2018), group music making (Bronson et al., 2018), Guided Imagery in Music (GIM) techniques (Blake, 1994; Story & Beck, 2017), Neurologic Music Therapy (NMT) techniques (Bronson et al., 2018), and performance (Vaudreuil, Bronson, et al., 2019). Specifics related to the music interventions and strategies were inconsistent, though some publications listed musical factors like use of the blues pattern (Bronson et al., 2018), instruments used (Bensimon, Amir, & Wolf, 2008; Bensimon et al., 2012), or strategies like the use of preferred music (Wellman & Pinkerton, 2015). Apart from the Bonny Method of GIM, most interventions appeared to be used in both individual and group treatment. Like the interventions used, treatment objectives also varied, but emotional expression and/or emotion regulation, the most common objective cited (n = 10), was addressed in both group and individual formats. Socialization/cohesion and/or decreasing loneliness/isolation was the second most common objective (n = 5), and social objectives were more commonly addressed in group formats. Other objectives addressed during music therapy included improvements in speech, motor, and cognitive functioning, decreasing discomfort (Vaudreuil, Avila, et al., 2019; Vaudreuil, Bronson, et al., 2019), improving symptoms (Story & Beck, 2017), and reducing anxiety and depression (Wellman & Pinkerton, 2015). Speech goals and improving symptoms appeared to be addressed more frequently in individual treatment format. Positive responses to music interventions were cited in both case presentations (Vaudreuil, Avila, et al., 2019) and research publications (Garrison, 2016; Wellman & Pinkerton, 2015), and veterans themselves cited the use of music to increase emotional expression (Bradt et al., 2019; Shing, 2016) and communicate their experiences to others (Bradt et al., 2019). It also appears that veterans have begun to request music therapy services (Spencer, 2013), and that veterans in the United States may be more likely to participate in music therapy services when offered at a local VA facility (Shing, 2016). See Table 3 for more information on treatment objectives and interventions/techniques used in clinical services.

Discussion

This scoping review provides an up-to-date synthesis of the available information on the use of music therapy interventions to promote health and improve functioning in military service members. A total of 27 publications from both peer-reviewed and grey sources are included in this review, with historical reviews, research publications, and case studies the most common types of publications found. As can be seen in the historical reviews, there was a close connection between music services for military personnel and the development of the music therapy profession in the early part of the 20th century (Robb, 1999). Furthermore, the positive response to music by service members increased recognition of the therapeutic value of music, and some of the practices outlined in the reviews include strategies still used by music therapists today.

Results from this review indicate that service members who participate in music therapy most commonly present with PTSD and TBI, though other conditions like MST, moral injury, and adjustment disorder are also present among those served. Moreover, as shown in Table 3, individuals served often have comorbid diseases, disorders, and/or impairments in functioning. Therefore, it is no surprise that working with military populations has been labeled a complex task (American Music Therapy Association, 2014; Olenick, Flowers, & Diaz, 2015; Steward, 2018).

Active music making has played an important role in music for military populations from the beginning, likely because the military considered active participation most beneficial (Rorke, 1996). Music making initially served as a source of entertainment, motivation, or recreation for service members (Robb, 1999; Rorke, 1996), but an increase in the clinical application of music (e.g., music interventions to address specific therapeutic outcomes) can be found in the more recent publications included in this review (e.g., Bradt et al., 2019; Bronson et al., 2018). Today, drumming appears to be the most widely utilized active music making intervention. This shift is consistent with the growing body of research that supports the therapeutic effects of active music making (Collins & Fleming, 2017; Raglio et al., 2016) as well as the widespread use of percussion in music therapy (Scheffel & Matney, 2014).

Service members participate in music therapy in both group and individual formats, and common treatment objectives can be seen in both formats. However, some objectives, like social objectives, were more commonly integrated in one format (i.e., group). Wheeler, Shifflet, and Nayak (2003) stressed that individual and group formats may be useful for different purposes, and the publications included in this review are consistent with this premise. Thus, it may be important to consider service members’ objectives when determining the structure of music therapy services.

The most common outcome targeted in the publications included in this review was improved emotional expression and/or emotion regulation, and this goal was addressed in both group and individual formats. Previous research has shown that emotion regulation is often poor among those with PTSD and TBI (Mantua, Helms, Weymann, Capaldi, & Lim, 2018), the most common conditions cited in the literature included in this review. It is important to identify effective treatment strategies that help individuals improve their ability to both express and regulate emotions. Kern (2016) suggested that music therapy may be an important pathway for communication and expression for those who do not respond in a conventional manner. Likewise, Lonsdale and North (2011) found that individuals use music to manage or regulate their emotions. This suggests that music interventions may be useful in expressing and managing emotions. Sena Moore (2013) highlighted specific strategies like music listening, singing, and improvisation that may be useful in music-based emotion regulation strategies. Though more research is needed on the possible use of music in treatment of emotion dysregulation (Hou et al., 2017), music therapy may be an affordable option that can safely and effectively meet the needs of military personnel who struggle with complex symptoms related to PTSD and TBI or other conditions (American Music Therapy Association, 2014; Kern, 2016).

Results from this review suggest that music therapy is well received by service members (American Music Therapy Association, 2014; Bensimon et al., 2008; Spencer, 2013), and the positive responses to music interventions cited in the historical reviews (Robb, 1999), case study presentations (Vaudreuil, Avila, et al., 2019), and research publications (Garrison, 2016; Wellman & Pinkerton, 2015) are consistent with research which has shown that individuals positively respond to music therapy services (Lane, Palmer, & Chen, 2019; Lin et al., 2011). Music therapy has potential to be a viable treatment option for those who have served in the military. However, the American Music Therapy Association (2014) has stated that access is an issue, delaying or deferring music therapy services. Currently, the number of music therapists employed in VA Medical Centers is small, with approximately 73 music therapists working in 49 VA Medical Centers. The largest numbers of music therapists are employed in facilities in New York (nine), Texas (seven), and Florida (seven), yet over half of the states do not have music therapists employed in VA Medical Centers (D. Otto, personal communication, December 7, 2018). More work is needed to improve access and the continuity of care for all service members.

Implications for Research

Ten of the 14 clinical publications included in this review have been published since 2015, which suggests an increased focus on music therapy services for military populations. Yet historically music therapy research across the military continuum has been inconsistent and episodic (American Music Therapy Association, 2014). Furthermore, most of the evidence included in this review consisted of historical reviews and case studies, which constitute lower levels of evidence. The use of evidence-based interventions is important in the VA health system, and evidence-based complementary and integrative approaches are a priority (U.S. Department of Veterans Affairs, 2018). More high-level research is needed to increase access to music therapy services among service members, which is consistent with calls for higher levels of evidence in other areas of music therapy research (Silverman, 2010).

Publications included in this review often lacked specificity, in some cases providing limited details on location, music therapy interventions, and specific objectives, among other factors. Identifying specific clinical goals, integrating methodological rigor, and providing clearer descriptions of music interventions needs to be included in future research to improve the quality of both of music therapy research (Robb, Burns, & Carpenter, 2011) and clinical practice (Raglio et al., 2015). Possible factors for inclusion are (a) service location (e.g., in Department of Defense/VA facilities), (b) participants’ diagnoses (e.g., PTSD and TBI), (c) participants’ branch of military service, (d) music therapy structure (e.g., group and individual format, etc.), (e) interventions used (e.g., drumming), (f) interventionist qualifications (e.g., board certified music therapist), (g) theoretical rationale, and (h) objectives addressed/related outcomes (e.g., emotion expression/regulation and socialization). It should be noted that clear music-based intervention reporting has been cited as an ongoing issue in music therapy (Robb et al., 2011, 2018), so this issue is not specific to music therapy with military populations. However, lack of this information impedes cross-study comparisons, interpretation, replication, and generalization of findings and lessens the scientific rigor and clinical relevance of publications (Robb et al., 2018).

Most of the publications included in this review focused on male service members, but it is important to consider women as their experiences may differ from men (Mattocks et al., 2012). Previous non-music therapy research cited listening to music as a coping strategy employed by women veterans (Mattocks et al., 2012) and previous music therapy research suggests that women respond to music with greater effect than men (Standley, 1995). As a result, music therapy may be particularly applicable to women service members. Similarly, much of what guides current practice related to common conditions found among service members like PTSD and/or TBI comes from populations outside of the military (American Music Therapy Association, 2014), and there is little information to guide practice with those who present with MST, moral injury, and/or adjustment disorder (Gimpel, 2018). Given the complexity of service members’ needs and the increased focus on issues like MST and adjustment disorder by the U.S. Department of Veterans Affairs (2015), there is a need for targeted research to guide practice in these areas. Likewise, future research should incorporate military families and caregivers, an area of increased focus, support, and research for VA officials (Shane, 2018). Family-based research may be especially important given that musical engagement has been shown to have benefits for military families (Clift, Page, Daykin, & Peasgood, 2016) and family members have reported positive benefits from music therapy participation for themselves and their loved ones in non-military settings (Lane et al., 2019).

Finally, as is the case with other areas in music therapy research, studies are needed that focus on specific interventions for specific diagnoses, define and describe music therapy interventions using accepted standards, and integrate consumers in the research process (American Music Therapy Association, 2015). Replication of high-priority studies should also be considered, particularly with signature conditions like TBI and PTSD, high volume conditions like PTSD, and problematic presentations like polytrauma (American Music Therapy Association, 2014). Future research should both inform and refine music therapy practices and protocols with military populations.

Conclusion

Music has long been used with the military to enhance quality of life, and today music therapy interventions are used to promote health, enhance quality of life, and improve functioning in military personnel. Evidence on the use of music interventions with military service members is still emerging, but results from this scoping review suggest that music therapy may be a viable and effective option for treating service members with PTSD, TBI, and other conditions. The anecdotal reports, white papers/ briefs, case studies, historical reviews, clinical program descriptions, and research studies included in this review suggest that music therapy interventions are well received by both active duty and veteran service members, and that active music therapy interventions like drumming are regularly used to increase emotional expression and/or regulation, increase socialization, and decrease loneliness. Music therapy services are offered in both group and individual format, and other objectives addressed in music therapy include improvements in speech, motor, and cognitive functioning, decreasing discomfort, improving PTSD symptoms, and reducing anxiety and depression (Wellman & Pinkerton, 2015). Publications related to music therapy and military personnel have increased since 2015, but research is still inconsistent. Several gaps have been identified, including the need for clinical research, the need for specific intervention research, and the need to explore military service members’ perspectives on the impact of music therapy interventions. Music therapy with military populations appears promising, but more is needed to ensure that the complex needs of military personnel are adequately met.

Acknowledgement

The authors of this paper would like to acknowledge the contributions of Creative Forces^®: NEA Military Healing Arts Network is 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.

References