Collaborative Songwriting Intervention for Veterans with Post-Traumatic Stress Disorder

Abstract

Objectives:

Given that veterans are significantly more likely to suffer from post-traumatic stress disorder (PTSD), traumatic brain injury (TBI), depression, and anxiety than civilians, yet current gold-standard treatments for PTSD are not effective for all patients, the present study sought to examine the feasibility and acceptability of a collaborative songwriting intervention (CSI) while exploring its potential effectiveness in improving physical and mental health outcomes for veterans with PTSD.

Design:

Ten veterans took part in the CSI. A variety of pre- and postintervention measures were administered, including the Measurement of Current Status (MOCS), the Coping Expectancies Scale (CES), the Post-traumatic Stress Disorder Checklist-Military (PCL-M), and the Patient Health Questionnaire-9 (PHQ-9). Participants also wore a Fitbit to track average heart rate, sleep, and step count.

Intervention:

The CSI consisted of each veteran meeting with a professional songwriter, trained specifically for co-writing original material with the veteran population. There were three phases of songwriting that took about an hour and 15 min total. Veterans were instructed to listen to their song daily for 5 weeks.

Results:

Participants reported that the intervention was helpful and relevant to them, and most participants (95%) would refer others to this treatment. We found that the CSI reduced participant's PTSD symptoms (d = 0.869), specifically the Numbing (d = 0.853) and Hyperarousal (d = 1.077) subscales. Depressive symptoms (d = 0.72) and stress reactivity (d = 0.785) also marginally decreased. There was no significant change in physiological data (i.e., sleep, no. of steps) from pre- to postintervention.

Conclusion:

These data suggest that a CSI is an acceptable intervention for veterans with PTSD that may also improve their PTSD symptoms.

Introduction

Post-traumatic stress disorder (PTSD) can develop following exposure to traumatic life events with symptoms of hypervigilance, intrusive re-experiencing, and physiological and/or emotional distress.¹ Veterans are at least three to eight times more likely than nonveterans to experience PTSD,² which negatively impacts overall quality of life and leads to higher mortality rates. For example, veterans with PTSD are four times more likely to report suicidal ideation³ and experience more physical limitations, higher unemployment, compromised physical health, and diminished well-being, even when controlling for other medical and psychiatric comorbidities.⁴

There are several robust, evidence-based treatments for PTSD; these include psychotherapy (e.g., cognitive processing therapy [CPT], prolonged exposure [PE] therapy) and psychopharmacology (e.g. selective serotonin reuptake inhibitors [SSRIs] and serotonin norepinephrine reuptake inhibitors [SNRIs]).⁵ However, standard psychotherapy interventions are often especially stigmatizing for military service members compared with civilians.⁶ Characteristically, veterans reach out to help others, but they do not like to seek help for themselves, especially treatment for a mental health condition,⁷ which can impact their ability to engage in evidence-based psychotherapy and pharmacotherapy interventions for PTSD.⁸ Furthermore, the gold-standard treatments for PTSD often have high dropout rates; therefore, veterans continue to struggle with PTSD despite the gains in pharmacological and psychotherapeutic interventions.⁷ For example, veterans who do engage in PE or CPT appear to have poorer PTSD treatment outcomes compared with civilians, often remaining symptomatic with complex comorbidities.⁹

Over the past several decades, therapeutic music interventions have gained popularity as adjunctive mental health treatments across a variety of clinical populations.¹⁰ More specifically, therapeutic songwriting is a form of intervention that engages patients in a collaborative songwriting process with a professional songwriter, during which the songwriter and client co-create and record lyrics that addresses the psychosocial, emotional, cognitive, and/or communication needs of the client [definition adapted from Baker and Wigram (2005), p.16].¹¹ In a study of 17 incarcerated males who underwent a 32-week collaborative songwriting intervention (CSI), participants were found to have improved adjustment to their incarceration along with increased personal skills.¹² The authors found the intervention facilitated trustworthy interactions among the incarcerated and helped to improve planning, pro-social, interpersonal, and emotional intelligence skills.¹²

To date, research has not been conducted to assess the therapeutic effects of collaborative songwriting for veterans diagnosed with PTSD. However, therapeutic music interventions at large have shown promising results within this population. For example, veterans (N = 205) with higher levels of affective dysfunction listened to music to manage emotional and cognitive problems.¹³ Furthermore, music has been used to help patients relax and “tell their story” while a therapist listens as part of the Bonny Method of Guided Imagery and Music approach.¹⁴ This music-centered therapy approach has been found to assist with managing PTSD symptoms of hyperarousal¹⁵ as well as help women with PTSD to reduce dissociative symptom and improve stress and interpersonal relationships.¹⁶

Given the promise of therapeutic music interventions and collaborative songwriting for clinical utility, Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, partnered with a nonprofit organization, Songwriting with: Soldiers, to pilot the first CSI with quantitative outcomes for veterans diagnosed with PTSD. The primary goal of the present intervention was to determine the acceptability and feasibility of implementing this new and innovative treatment in a clinical setting. We also sought to determine if there would be any reduction in reported symptoms of PTSD (specifically hyperarousal) and depression as well as a potential improvement in participant's physical activity and sleep (as measured by a Fitbit) among the veterans undergoing the intervention.

Materials and Methods

Participants

Recruitment and data collection for this pilot were approved by the Partners Healthcare Institutional Review Board. Eligible participants were service members and veterans between the ages of 18 and 65 years who had previously participated in Home Base's 2-week Intensive Clinical Program (ICP) for PTSD, expressed interest in participating in research during their ICP intake evaluation, and lived locally within New England to attend study visits. Thirty-four former ICP patients were approached for participation and a total of 10 consented. The average time elapsed since participation in the ICP ranged from 1 to 17 months. Participant (N = 10) ages ranged from 28 to 52 years (M _age = 35.0, SD = 7.0). Most participants were male (90%), married (50%), veterans (80%), and all had been deployed at least once (Table 1). Years served ranged from 3 to 18 years, with an average of 8.2 years. Most participants (90%) had a current or past anxiety disorder and 60% had a history of or current traumatic brain injury (TBI). All had a diagnosis of PTSD (100%). Diagnoses were determined through participation in the ICP, during which participants endorsed significant PTSD and depression symptom improvement, respectively, from pre- to postprogram [t(8) = 8.98, p < 0.001; t(9) = 10.28, p < 0.001]. Two participants were ultimately lost to follow-up within week 4 for unknown reasons and dropped out of the study.

Table 1.

Demographic Characteristics

Variable	Frequency, n (%)
Sex
Male	9 (90)
Female	1 (10)
Age	M _age = 35
Marital status
Divorced	2 (20)
Married	5 (50)
Never married	1 (10)
Separated	—
Widowed	—
Single	2 (20)
Military status
Active duty	2 (20)
Veteran	8 (80)
Deployed
Yes	10 (100)
No	—
No. of deployments
1	5 (50)
2	4 (40)
8	1 (10)
Military branch
Air force	2 (20)
Marine corpse	4 (40)
Army	2 (20)
Navy	2 (20)
Coast guard	—
USPHS	—
Years served
3	2 (22)
4	2 (22)
8	1 (11)
9	1 (11)
10	1 (11)
15	1 (11)
18	1 (11)

Procedure

All participants were consented by a Principal Investigator and provided with a Fitbit Charge 2 device. Participants were told to wear their Fitbits at all times throughout the duration of the study and to keep these devices charged and synced with the wearable device app on their smartphone. Each week of the intervention, participants were required to complete a survey in which they self-reported their daily average heart rate, sleep, and number of steps as measured by the Fitbit.

The CSI visit involved every veteran meeting with a professional songwriter, trained specifically for co-writing collaborative music that works to build trust, release pain, and form new bonds, all aspects that are thought to specifically benefit veterans. The first phase of the intervention began with the songwriter and the veteran getting to know one another for about 10 min. The songwriter asked demographic, vocational, family, and military experience questions while paying attention to specific details that might be useful in the songwriting process. The second phase lasted 20 min and involved the songwriter engaging the veteran in a participant-guided conversation that was informed by the previous demographic information provided by the veteran. The songwriter typically asked further questions about the veteran's military experience and/or trauma (e.g., “Can you tell me about your military service?,” “What does it mean to you? Why?,” and “How does it impact your life today?”); therefore, most individuals chose to discuss their military trauma; however, this was not a requirement. The songwriter then used open-ended prompts to encourage the participant to explore associated feelings with the narrative. In the third phase, which lasted 45 min, the songwriter and participant collaboratively incorporated the narrative and associated emotions into song lyrics. The chorus was written first, and then, two to three verses were typically added. During the last phase, the songwriter worked to pair appropriate melodies with the created lyrics based on participant feedback.

Once written, the song was recorded and downloaded to a USB drive that could be worn as a bracelet for convenience. Participants were instructed to listen to the song daily for the 4 weeks following the songwriting session, acting as a form of exposure to the challenges and solutions included in their personal narrative/song. Similar to the exposure component of prolonged exposure (PE) therapy for PTSD,¹⁷ it was crucial that participants not only created the song (i.e., underwent the treatment) but felt comfortable with the material by repeatedly listening to the song (i.e., continued the exposure). Participants completed a survey on feasibility and acceptability of the songwriting experience immediately upon completion of writing and recording the song, and at the follow-up time point (4 weeks postintervention). An exit interview was also completed 4 weeks postintervention. Thus, the CSI is a 4-week intervention including the songwriting visit as well as the 4 weeks of listening to the song.

Measures

Participants completed demographic questionnaires and were instructed to complete a battery of self-report psychological assessments at three time points: 2 weeks before the start of the CSI, at the time of the songwriting visit, and 4 weeks after the songwriting visit. These assessments included the Measurement of Current Status (MOCS, α = 0.84), the Coping Expectancies Scale (CES, α = 0.93), the Post-traumatic Stress Disorder Checklist-Military (PCL-M; α = 0.89), and the Patient Health Questionnaire-9 (PHQ-9, α = 0.89).

The MOCS is a 13-item questionnaire that measures an individual's ability to react to daily stress. Individuals read 13 statements that propose a scenario involving stress reactivity and consequently select how much they resonate with the statement on a 5-point Likert scale, 0 being I cannot do this at all and 4 being I can do this extremely well. Higher scores indicate better reactivity to stress.¹⁸ The CES is a 25-item measure of resilience, created by the Benson Henry Institute, adapted from the Posttraumatic Growth Inventory¹⁹ to reflect current functioning in the domains of appreciation for life (AL), adaptive perspectives (AP), personal strength (PS), spiritual connectedness (SC), relating to others (RO), and health behaviors (HB; not part of the PTGI). The CES total score can range from 0 to 125, with higher scores indicating greater resilience.²⁰ The PCL-M is a 17-item measure administered to assess PTSD symptoms based on the DSM-IV-TR criteria, specifically within military populations. An individual can score anywhere from a 0 to 85, with higher scores indicating more severe PTSD symptomology.²¹ The PHQ-9 is a 9-item measure utilized to assess the severity of depressive symptoms present within the last 2 weeks according to the DSM-5 criteria. Scores can range from 0 to 27, with a score below 9 indicating mild-to-low depressive symptoms and scores above 10 indicating moderate-to-severe depressive symptoms.²²

At their final visit, participants also completed semi-structured exit interviews with a study staff member. Questions investigated the acceptability of the intervention by means of feedback about study methods, CSI experience, ability to adhere to study requirements, as well as favorite and least favorite aspects of the study.

Data analysis

Paired t-tests (p < 0.05, two-tailed) were used to analyze the change of psychological and physiological data between pre- and postintervention. All psychological data were self-report, and physiological data were measured via the Fitbit on a weekly basis and then reported by participants. Participants were sent weekly online surveys and asked to report their average sleep (hours), number of steps, and heart rate (beats per minute) over the past 7 days. The feedback interviews were transcribed and analyzed using inductive thematic analysis, a form of analysis that examines and determines patterns within the qualitative data. Trained study staff completed the coding process by identifying themes and subthemes within participant feedback until all answers were categorized. A qualitative codebook was created from the themes²³ (Table 2). Data were iteratively recoded using this book until intercoder reliability was reached (>80.0%).²⁴

Table 2.

Themes and Subthemes as Determined by Qualitative Analyses

Theme	Subtheme	Example quote 1	Example quote 2
Components of the CSI	Telling the story	“I felt comfortable opening up as the hours went on. I could be there telling him a story and he'd be like, ‘That! That!’ ”	“At first I was kind of anxious, it's a new person I'm telling my story to. But within a few minutes I felt comfortable.”
	Creating the song	“He had that understanding of how personal this song was … I definitely felt that it was a true collaboration.”	“Once I started talking to him about my time in the army … he started coming up with all the metaphors for that.”
	Listening to the song	“It definitely made me re-analyze parts of my traumas. The negative feelings are still there, but … there are really some positive experiences associated with the incident.”	“… for the first week I was pretty emotional every time I listened to it. It became like exposure therapy almost … I can listen to it now, sometimes I'll get tears.”
	Sharing the song	“I think everyone I played it for, if they weren't in tears, they were just about after hearing it.”	“It's so much easier … You just have people listen … and they have a baseline of it.”
External influencing factors	Influence of prior participation in ICP	“I'd say the ICP helped … to open up and initiate some ideas of trust.”	“I've been with home base for a year now after the ICP, so I was comfortable expressing my experience.”
	Prior exposure to/enjoyment of music	“I think that my being a musician made this a different experience for me than maybe someone else who wasn't.”	“Driving in I was kind of anxious but the more I thought about it, this is music—and I'm musically inclined.”
	Influence of other life events	“I was going to get a divorce and then things kind of worked out. This helped, it was odd.”	“I currently live in homeless veteran housing, a 2-bedroom apartment, with 3 children and one on the way.”
	Influence of study on quality of life	“These past few weeks have been pretty damn good!”	“It re-grounded me with where my goals were.”
Logistical aspects of study	Waiting time	“Everything was easy, the way appointments were arranged. I never waited.”	“I have a feeling that if I would've been here on time there wouldn't have been a wait.”
	Length of sessions	“The only thing I could suggest as an improvement is a little more time with the songwriter.”	“I feel like more time in the session itself would be good for anyone.”
	Staff	“You guys are great. I cannot speak bad about anyone in this program.”	“You guys know PTSD and TBI, you get that sometimes things slip my mind.”
	Frequency listened to song (Rx adherence)	“I carry it around with me, I play it in the motorcycle and in the jeep.”	“I've tried to listen to it at least once a day, but I'm shooting for two.”
	Experience filling-out surveys	“They serve as a reminder of the progress that I've made, so I really don't mind them as much.”	“I really appreciate the reminder ‘hey you missed last week, fill it out this week if you can!’ ”

CSI, collaborative songwriting intervention.

Results

Participants who completed the study to follow-up (N = 8, 80%) rated the intervention as helpful and relevant and endorsed willingness to recommend this intervention to others. Based on inductive thematic analysis, we found three major themes and several subthemes from the qualitative interviews (Table 2). The first theme includes components of the CSI: telling the story, creating the song, listening to the song, and sharing the song. The second theme centered on external influencing factors: prior participation in Home Base's ICP, prior exposure to/enjoyment of music, influence of other life events, and influence of study on quality of life. The last theme characterized logistical aspects of the study: waiting time, length of sessions, staff, frequency listened to song, and experience completing the surveys.

Among the N = 8 final pilot participants, PTSD symptoms (assessed with the PCL-M) showed a 33% decrease in symptoms between baseline (M = 46.9, SD = 16.6) and endpoint (M = 39.0, SD = 13.0), [t(7) = 2.54, p = 039; Cohen's d = 0.896]. There was also a difference on the PCL-M Numbing [t(7) = 2.41, p = 0.047; Cohen's d = 0.853] and PCL-M Hyperarousal [t(7) = 3.05, p = 0.019; Cohen's d = 1.077] subscales. Depressive symptoms (as assessed with the PHQ-9) marginally decreased by 22% (p = 0.079). There was also a marginal increase in coping skills (as assessed with the MOCS) over the study duration (p = 0.06) (Table 3).

Table 3.

Means for N = 8 Participants Who Completed Baseline and Endpoint Psychological Measures and Means for N = 6 Participants Who Completed Baseline and Endpoint Fitbit Measures

	Mean at baseline	SD at baseline	Mean at endpoint	SD at endpoint	t-Value	Co-hen's d
Measure	N = 8
PHQ-9 Total Score	11.06	5.60	8.38	5.55	2.05	0.723
PCL-M Total Score	46.88	16.62	39.00	13.04	2.54^*	0.896
PCL-M Re-Experiencing Subscale	11.81	5.65	10.63	3.93	1.30	1.128
PCL-M Avoiding Subscale	4.94	2.48	4.75	2.77	0.28	0.101
PCL-M Numbing Subscale	14.63	5.12	11.63	4.60	2.41^*	0.853
PCL-M Hyperarousal Subscale	15.50	5.40	12.00	5.07	3.05^*	1.077
CES Total Score	67.38	18.07	70.88	21.31	−0.67	0.238
CES Adaptive Perspectives Subscale	15.31	4.91	16.63	5.37	−0.81	0.286
CES Personal Strength Subscale	14.25	3.65	14.75	4.98	−0.39	0.140
CES Spiritual Connectedness Subscale	5.56	2.72	5.13	2.36	1.11	0.388
CES Relating to Others Subscale	16.94	4.64	17.13	6.15	−0.13	0.048
CES Health Behaviors Subscale	5.38	2.12	6.63	2.07	−2.50^*	0.888
CES Appreciation for life Subscale	9.94	2.34	10.63	2.45	−0.90	0.321
MOCS Total Score	23.88	7.25	28.63	11.56	−2.22	0.785
MOCS Relaxation Subscale	3.38	1.90	4.38	2.45	−1.48	0.526
MOCS Awareness Subscale	6.63	2.75	7.63	2.56	−2.08	0.739
MOCS Assertiveness Subscale	5.25	1.63	6.00	2.93	−0.83	0.294
MOCS Coping Subscale	8.63	2.50	10.63	4.34	−1.98	0.703
	N = 6
Average HR	65.33	8.06	66.50	7.77	−1.18	0.484
Average sleep (h)	6.62	068	6.41	0.85	0.60	0.250
Average no. of steps	7480	3483	8314	4040	−1.08	0.443

p < 0.05, ^** p < 0.01, ^*** p < 0.001.

CES, Coping Expectancies Scale; HR, heart rate; MOCS, Measurement of Current Status; PCL-M, Post-traumatic Stress Disorder Checklist-Military; PHQ-9, Patient Health Questionnaire-9; SD, standard deviation.

There were no notable changes in physiological data (average heart rate, average sleep, and average number of steps) from pre- to postintervention (Table 3). There was a noteworthy relationship, however, between number of times listened to a song and the degree of change in sleep (r = 0.80, p = 0.017) and average number of steps (r = 0.79, p = 0.019). This relationship was not present for changes in average heart rate (r = 0.67, p = 0.067).

Discussion

The present study sought to investigate the feasibility and acceptability of a CSI on veterans with PTSD while exploring its potential effectiveness for improving physical and mental health outcomes. Most importantly, the intervention was rated as highly tolerable by participants based on their exit interviews suggesting that a CSI is a promising form of innovative treatment among the veteran population. Several themes elucidated through qualitative analysis were centered around positive aspects of the intervention. Participants noted feeling comfortable “opening-up” about their stories with professional songwriters and sharing their song with others as a means of “re-analyzing” parts of their traumas. Such findings are crucial in informing new interventions that might be better able to engage this population in treatment.

Given our small sample size, we were not powered to determine the effectiveness of the CSI. However, these preliminary findings suggest that the CSI may have improved veteran's PTSD symptoms and marginally improved their depressive symptoms and overall coping skills. We hypothesize that these reductions in PTSD symptoms, specifically avoidance and hyperarousal, may be due to the CSI gently exposing veterans to their trauma. By repeatedly listening to their song over the 4-week study period, we hypothesize that participants begin to habituate to their trauma experience (which is typical during PE therapy), such that the heightened physiological response and avoidance associated with their trauma are dampened.²⁵ Future study is warranted to determine the mechanism for CSI. We did not find any changes in physiological data, suggesting that a CSI has less of an impact on physical functioning, although trends were in the right direction for improvements in heart rate and number of steps. Therefore, it is possible with more participants and/or a longer follow-up period that we may have observed more substantial changes. This is further supported by evidence that better adherence to the intervention (i.e., number of times participants listened to the song) was associated with positive change in sleep and physical activity.

Limitations to this study include small sample size, self-report of the physiological measures (i.e., participants reported data based on their Fitbit data), lack of a control group, and challenges with ethnic and gender diversity, although our sample is representative of veterans in Massachusetts.²⁶ Also, although all participants had previously received a diagnosis of PTSD during their participation in Home Base's ICP, we did not verify what the current status of their diagnosis was. Furthermore, previous participation in Home Base's ICP might have impacted patient engagement in the intervention due to previous familiarity with the clinic and/or study staff. Future studies should utilize larger, more controlled, and randomized trials to continue to investigate the effect of CSIs as a PTSD treatment for veterans as well as its acceptability and feasibility.

Footnotes

Acknowledgments

We would like to acknowledge the Songwriting With:Soldiers (SW:S) team for helping us with this work. Specifically, thank you to Darden Smith (co-founder and professional songwriter at SW:S), Mary Judd (co-founder and program director of SW:S), Kristin Starling (executive director of SW:S), and James House (professional songwriter) for their dedication to this project.

Author Disclosure Statement

L.G.S.: Royalty, New Harbinger; Personal Fees, United Biosource Corporation, Clintara, Bracket, and Clinical Trials Network Institute; Grant/Research Support, National Institute of Mental Health, Patient Centered Outcomes Research Institute, American for Suicide Prevention, and Takeda.

Dr. Spencer has, in the last 3 years, received research support or was a consultant from the following sources: Avekshan, Lundbeck, Sunovion, the FDA, and the Department of Defense. Consultant fees are paid to the MGH Clinical Trials Network and not directly to Dr. Spencer. Dr. Spencer received support from Royalties and Licensing fees on copyrighted ADHD scales through MGH Corporate Sponsored Research and Licensing. Through MGH corporate licensing, Dr. Spencer has a US Patent (#14/027,676) for a nonstimulant treatment for ADHD and a patent pending (#61/233,686) for a method to prevent stimulant abuse.

Funding Information

This research was supported by Home Base through unrestricted departmental funds.

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