A Music Therapy Trauma-Informed Care Treatment Manual for the Forensic Mental Health Setting by Amy Smith, MT-BC A Thesis Submitted in Partial Fulfillment of the Requirement for the Master of Arts Degree Master of Arts in Music Therapy Program in the Departments of Graduate Studies and Music and Theatre Saint Mary-of-the-Woods College Saint Mary-of-the-Woods, Indiana December, 2020 Abstract The growing awareness of the potential impact of traumatic experiences has increased throughout health care facilities across the United States in recent years (Maul, 2017; Tello, 2019). Research has shown the effectiveness of using trauma-informed care interventions when working with the forensic mental health population across many allied health professions (Carr et al., 2012; MacIntosh, 2003; Sajnani, 2019; Sutton, 2002). As this recognition has led to an increase in research, it has also highlighted a gap within the field of music therapy. Those working within forensic mental health settings face the complexities of trauma permeating throughout their work. This project was developed to serve as a guide to effective interventions music therapists can use when working in forensic mental health settings. A 14-week music therapy session plan includes psychoeducational components about trauma and skills that are imperative for group members to develop in order to navigate life. ii Acknowledgements I would like to give special thanks to Annette Whitehead-Pleaux, M.A., MT-BC for believing in me from the beginning. Your wisdom, inspiration, and thoughtfulness throughout this entire process was greatly appreciated. I would also like to thank Dr. Tracy Richardson, Ph.D., MT-BC for providing guidance and encouragement to undertake the creation of this project. Thank you to my thesis committee members, Dr. Yasmine Iliya, Ph.D., MT-BC, and Dr. Katherine Price, Ph.D., as well as my evaluators, Kim Lloyd, M.A., MT-BC and Steven Franco- Santiago, M.A., MT-BC, for your support. Thank you to my parents, Bob and Linda Smith, for your continued love and unwavering belief in my abilities; to my sister, Mindy; and to my cohort members, I am so glad we went on this journey together: Laetitia Brundage, MT-BC, Ashley Carroll, MT-BC, Heather Johnson, MT-BC, Brianna Larsen, MT-BC, Kristen Ney, MT-BC Corinne Pickett, MT-BC, Alison Rene, MT-BC, Bethany Rice, MT-BC, and Kazuko Robinson, MT-BC. iii TABLE OF CONTENTS ABSTRACT .................................................................................................................................... ii ACKNOWLEDGEMENTS ........................................................................................................... iii CHAPTER I. INTRODUCTION ................................................................................................... 1 Definitions ............................................................................................................... 3 Purpose Statement ................................................................................................... 4 II. REVIEW OF LITERATURE .................................................................................. 7 Incarceration and Forensic Settings ......................................................................... 7 Mental Illness in the Forensic Settings .................................................................... 9 Trauma .................................................................................................................. 10 Trauma and Aggression ......................................................................................... 13 Trauma-Informed Care .......................................................................................... 14 Cultural Considerations ......................................................................................... 15 Music Therapy ....................................................................................................... 17 Problem Statement ................................................................................................. 20 III. DEVELOPMENT .................................................................................................. 21 Design .................................................................................................................... 21 Procedure ............................................................................................................... 21 Evaluation .............................................................................................................. 22 IV. THE PROJECT ..................................................................................................... 23 Appendices ............................................................................................................ 92 V. REFLECTION ..................................................................................................... 109 REFERENCES ................................................................................................................ 112 Introduction The following account is one of a fictional character name Tyler. Tyler’s story may help the reader begin to understand how trauma impacts mental health and incarceration. When Tyler turned 13 years-old, he was initiated into a gang; after all, it was what everyone in the neighborhood was expected to do. By the age of 15 he witnessed one of his friends killed in a knife fight, and he started carrying a gun as a result. He had a few run-ins with the police, which he did not take seriously. Tyler’s life at home was not much easier. His mom was always going from boyfriend to boyfriend, from one domestic abuse relationship after another. It was a life of kicking, yelling, hitting, slamming doors, and drunken phone calls to the police. Maybe that was why he joined a gang; to feel like a part of a family. Sleep was his only way to escape the cycles of violence in his life; however, his dreams quickly turned into nightmares of gang and domestic violence making it hard to even sleep. To make matters worse, he frequently experienced flashbacks of his friend dying when he was awake. Three days after Tyler’s eighteenth birthday, he was the perpetrator in a drive-by shooting that left him with a 22- year to life sentence. Two years into his prison term, Tyler began talking to his counselors about his experiences and was diagnosed with post-traumatic stress disorder (PTSD). Because Tyler had become so desensitized to the trauma and violence at home, he had no insight into his behaviors that perpetuated the same cycles in other relationships. He had no place that was free from the chaos and violence that was happening around him. This story was his normal, everyday life. Hearing stories similar to Tyler’s are not uncommon for someone working within the forensic setting. Robinson (2018) stated, “Experiences of early childhood trauma are common among young people in the Criminal Justice System (CJS)” (para. 4). In addition, “Compared to the general population, children in the CJS are three times more likely to have 2 mental health problems- often anxiety, depression, and drug and alcohol dependence” (Robinson, 2018, para. 4). Due to the prevalence of this lifelong exposure to violence in those who experience incarceration, a trauma-informed approach would be broadly appropriate. Many organizations nationwide are beginning to consider the symptoms of trauma more seriously and are spending time and resources training health care professionals on trauma- informed care practices (Maul, 2017; Tello, 2019). Staff and patients within these organizations are subject to trauma either directly or through vicarious trauma. The focus of this paper is with the forensic mental health facility and its patients. Within forensic settings, patients with serious mental illness use multiple maladaptive coping strategies to manage their experienced trauma such as substance use as well as criminal and aggressive behavior. Due to the complex nature of the forensic mental health population, it is important to capture the unique aspects and variables with each patient. The systems that house this population are generally viewed as dangerous for patients as well as for staff. Working with the patients in the forensic mental health system from a trauma-informed care lens can be an opportunity to decrease violence toward staff and patients as well as provide patients an environment wherein their experiences are validated. One of the many treatment resources offered within the forensic mental health setting is music therapy. Within the music therapy profession in the United States, there has been an increased acknowledgement of physical and psychological trauma as well as the ways in which music therapy interventions can address the impact of this trauma (Carr et al., 2012; MacIntosh, 2003; Sajnani, 2019; Sutton, 2002). Compton-Dickinson and colleagues (2013, 2017) produced much of the music therapy literature dealing with the forensic mental health population in the United Kingdom. Due to the complex nature of the forensic mental health setting as well as the lack of well-developed music therapy treatment interventions that target the different aspects that 3 afflict the population, this writer intends to create a trauma-informed music therapy treatment manual. This manual will provide music therapists with tools to inform treatment interventions with this unique population, including trauma-informed care approaches to music therapy, assessment tools,