I arrived at the Orlando VA Medical Center in October 2012. I quickly became immersed in the Evidence Based therapies favored in the VA and a year later became the first psychologist at the Daytona Beach Multi-Specialty Clinic to become certified in Cognitive Processing Therapy. I am a firm believer in evidence-based practice for PTSD. However, I also recognize that there are many pathways to healing. Finding one of these alternative pathways has had perhaps as profound an effect on me as it has on the many veterans who have joined me on it.
In late 2014 I stumbled across a story about a program teaching guitar to veterans. A few days later I was taking my first steps on the journey to founding the Port Orange/New Smyrna Beach chapter of Guitars for Vets. Guitars for Vets (G4V) is a 501(c)3 organization providing lessons and instruments to disabled veterans throughout the country. Although they recently hit 100 chapters, it started off in 2007 with two people - a Milwaukee guitar instructor who was introduced to a Vietnam-era Marine who had long wanted to learn guitar but felt that his PTSD symptoms were too impairing. Within a few months he recognized that he was not only learning the instrument, but he was also enjoying the social interaction. In fact, he realized that many of his PTSD symptoms had improved. They shared this finding with the Milwaukee VA hospital and the first Guitars for Vets chapter was born. In 2011 a study evaluated the effectiveness of this 6-week program on PTSD symptoms. The model evaluated included one-hour individual training and group instruction session each week, all led by volunteer guitar instructors. Forty veterans described as having “significant PTSD symptoms” were recruited and randomized to either an immediate entry or 6-week delayed entry group. The results were impressive. All veterans completed the program. PTSD symptoms (measured by PCLC scale) were reduced by 21%. Depression symptoms (measured by Beck Depression Inventory) were decreased by 27%). Perhaps most importantly, health-related quality of life (measured by the EuroQoL) was increased by 37%. From these findings, a partnership between G4V and the VA was created and the program expanded to 40 chapters by 2014. There were 80 on June 29, 2018 when I started the first group lessons in Port Orange.
As Guitars for Vets grew nationally, the program became more flexible to meet demands and resources at different chapter locations. Today there is a basic structure for all chapters, but within that there is great flexibility. Many chapters consist of one or two instructors who give individual lessons only, with graduation occurring after the 10th lesson. Other chapters are able to teach G4V groups and then select veterans from those groups for individual lessons, often based on their participation. Our program runs a little differently than most. Veterans generally start off in groups of 6-7 with 2 volunteer instructors. Veterans are not just learning the mechanics of playing guitar, but from Session One are instructed in the foundations of music theory as well. We train musicians who just happen to be using the guitar as their voice right now, but with that understanding of the relationships between notes they will be able to teach themselves other instruments. In this spirit, some of our graduates have go on to teach themselves banjo, Puerto Rican Cuatro, and one is currently teaching himself mandolin. Veterans generally remain in the groups until they develop the basic muscle memory for open chords and then transition to individualized individual sessions. After 10 individual lessons they graduate the program, receiving a diploma and challenge coin, new guitar with case/gig bag and approximately $150 worth of accessories. Along the way, they get a lot more.
When I started the program I believed that once veterans attained the ability to express their emotions through steel strings they would start benefiting. What I found was that G4V veterans were self-reporting significant benefit after only four to six weeks. They were telling their guitar instructors the program had helped them become more social and more confident, feel better about themselves, given them a sense of pride, and were more willing to take on other new challenges. Although this was great to hear, I did not understand how it was happening. A third and then a then fourth cohort started. One day I noticed a pattern occurring – G4V veterans would come to me weekly saying “Dr. K, I still suck but I haven’t given up yet.” Then one week they would come in and instead profess “I noticed I got from G to D a little bit faster this week! I know I can do this, I just haven’t been practicing enough!” Then it clicked. Learned Helplessness. Many veterans who come into G4V have been in mental health treatment for a long time and tried many things outside of mental health treatment to improve their quality of life, but their experience has been that nothing makes a difference. As a result, they come to believe that they do not have the power to change their lives and give up. I hypothesize that at the moment they realize they got just a little bit faster between the G and D chords, evidence that they ARE learning the guitar and CAN learn the guitar, they stop believing that nothing they do will make a difference. In support of this, one of the first G4V graduates when speaking to the public about how the program had helped him explained “I learned that I can learn again. If you haven’t been in the military or gotten a TBI you might not understand just how powerful that is.”
Another thing happens when learned helplessness is broken - the locus of control shifts from external to internal. Internal locus of control (the belief that we make what happens in our lives happen) has been shown to be associated with greater effort and more willingness to take risks, higher motivation and perseverance, and greater self-esteem – the same things these veterans were reporting. One G4V veteran, after being in the groups for only 2 months, attempted to explain the significance of what was happening for him to his instructors who had never experienced PTSD: “You don’t understand. Two months ago I wouldn’t have left my house for anything but the VA. Now I’m more social. I feel confident. I even volunteered to be the President of my HOA, where I have to actually TALK to people!”
I have come to realize that the impact on learned helplessness and locus of control is only part of the equation. Our program promotes socialization, which can significantly impact and be impacted by PTSD. When a military veteran transitions from military to civilian life they often experience a loss of social connectedness, an individual’s internal sense of belongingness to the social environment (Kintzle, Barr, Corletto, & Castro, 2018). As a result, these veterans feel detached from the world around them and often isolate. This is particularly true of veterans dealing with combat trauma, who will report that they only feel that they “belong” with other veterans. This belief is common in veterans beginning the G4V program. However, as they are learning about the foundations of music, they are learning to think differently about music. As one G4V student explained “I am listening to music again now. Not just music I like, but music I would have never listened to before, because I hear it differently now.” They begin to practice more social behaviors in the small groups, but we also encourage students to go out to the various community open guitar jams happening nightly – and they do. As they are out in these places, joining with others playing instruments, thinking differently about music, they start to “feel like a musician.” G4V vets no longer say “I’m a vet and I only feel like I belong with other veterans” but recognize “I’m also a musician and feel like I belong with other musicians too.” With that their social connectedness expands rapidly.
Digging even further, G4V students report changes in two other important constructs: self-esteem and self-efficacy. Some also report using the guitar as a distractor when they experience nightmares. As one veteran explained “My nightmares have gone down, but not completely away. But now when I do wake up from a nightmare I grab my guitar and my mind focuses on my hands instead of the nightmare.” Some G4V students return to the program as volunteer instructors. Others are learning so that they can play for others in hospice or hospital care. Perhaps most importantly, those who put the effort in are engaging in daily meaningful and purposeful activity. In Man’s Search for Meaning, Victor Frankl suggested that we all have an inner need for purpose and meaning in life. He said that this purpose did not need to be ‘given from God’, but rather was just a sense that one was moving towards a meaningful goal. For the veteran who has always wanted to learn to play an instrument, every practice session is moving them towards that. For the veteran who just wants to challenge himself/herself to something new, ditto. I started out thinking that the end product was where the healing happened, and I continue to see new ways in which the journey itself is healing these veterans.
I also recently discovered that building this program has helped me find something in myself that I did not even realize was missing. Before I became a psychologist I was an amateur rock star, a local guitar hero. I had worked hard on my craft from the age of 13 and enjoyed being recognized for my place in the local music scene – I felt special. I left that to forge my way in a new field and have had some success, but it was not until my G4V program started gaining recognition in the community that I realized I had missed that part of me that was an important part of my music community. Guitars for Vets has been a personal bridge connecting the purpose and meaning I found as my younger self with who I am today. The power of music to transform and heal cannot be overstated.
Kitzle, S, Barr, N, Corletto, G, and Castro CA (2018). PTSD in U.S. Veterans: The Role of Social Connectedness, Combat Experience, and Discharge. Healthcare, 6(3), 102.
VA Office of Research and Development. (2011). Guitars for Vets: Evaluating Psychological Outcome of a Novel Music Therapy (Clinicaltrials.gov Identifier NCT01229904). Retrieved from https://clinicaltrials.gov/ct2/show/NCT01229904