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Acute care mental health workers’ assumptions and expectations of music therapy: A qualitative investigation
The Arts in Psychotherapy 59 (2018) 94–100
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The Arts in Psychotherapy journal homepage: www.elsevier.com/locate/artspsycho
Research Article
Acute care mental health workers’ assumptions and expectations of music therapy: A qualitative investigation
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Michael J. Silvermana, , Jennifer Bibbb a b
University of Minnesota, USA University of Melbourne, Australia
A R T I C LE I N FO
A B S T R A C T
Keywords: Music therapy Staff Perceptions Expectations Acute care Mental health Qualitative
A small number of papers indicate that music therapists are interested in how their work is perceived by other healthcare professionals. The research reported in this paper examined assumptions and expectations of music therapy by mental health professionals in order to understand better how music therapists might use effective strategies to empower greater knowledge of their practice and services. We conducted semi-structured interviews with seven clinical staff members of an acute mental health facility that did not have music therapy. Data were analyzed via the six phases of thematic analysis. Member checking and trustworthiness were also used. Guided by the interplay between the user, music, and music therapist that conceptualizes music therapy, we identified five emerging themes concerning assumptions and expectations of music therapy: 1) the client – potential benefits to service users, perceptions of the appropriate service user ‘type;’ 2) the music therapist – unawareness of the music therapy as an established profession with required training and skills; 3) the music – types of music ideal for therapeutic impact; 4) music therapy – treatment expectations; and 5) the context – music therapy would augment and complement existing psychosocial treatment programming. Participants tended to be unfamiliar with most aspects of music therapy and continued education and advocacy are warranted. Emerging themes can provide a framework for information to be included within educational in-services. Suggestions for future research, limitations, and implications for music therapists are provided.
Introduction Although a high percentage of music therapists practice in mental health settings in the United States (AMTA, 2017), there remains a need for additional services to increase access to care. Potentially hindering the development of additional music therapy services, many non-music therapy mental health care workers have limited knowledge about the profession. A small number of papers indicate that music therapists are interested in how their work is perceived by other healthcare professionals. In order to address this gap in the literature, the research reported in this paper examined assumptions and expectations of music therapy by mental health professionals in order to understand better how music therapists might use effective strategies to empower greater knowledge of their practice and services. Literature review Music therapy remains a relatively small profession and many related health care providers may not be aware of the training music
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Corresponding author. E-mail address: [email protected] (M.J. Silverman).
https://doi.org/10.1016/j.aip.2018.05.002 Received 31 October 2017; Received in revised form 7 April 2018; Accepted 9 May 2018 Available online 09 May 2018 0197-4556/ © 2018 Elsevier Ltd. All rights reserved.
therapists receive, the populations music therapists serve, how interventions target clinical objectives, and supporting research. This lack of knowledge may adversely impact people’s perceptions of the field, expectations for treatment, and subsequent access to music therapy treatment for mental health service users (henceforth “users”). For example, if staff members on a mental health unit are unaware of the field and supporting literature, they may not encourage administrators to hire music therapists. Even if music therapy is available as a psychosocial service but the unit staff are unaware of exactly what it is and can do for users, the workers may not recommend that users attend music therapy sessions or provide music therapy referrals. Thus, as collaborative and integrated members of the treatment team (Twyford & Watson, 2008), staff members’ assumptions and expectations of music therapy are consequential and warrant scientific investigation. There is a small research base reporting staff members’ perceptions of music therapy. Hoskyns (1988) published one of the first of these studies and included both staff and service users to obtain a more holistic perspective. In this investigation, the researcher provided group-based music therapy for adult offenders and briefly interviewed
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2015). Increased awareness via education and advocacy can potentially result in additional positions, an increase in referrals and access to care, and additional support for music therapy that may encourage users to attend sessions. However, there is a lack of research concerning what information should be included within music therapy in-services. To date, there is limited published literature concerning staff members’ knowledge of, assumptions, or expectations of music therapy prior to in-service training, observation, or direct experience. Some of these data can be found in music therapy literature wherein pretests were used to assess baseline levels of knowledge before an in-service was provided. For example, in a study using pre- and posttests, Darsie (2009) examined interdisciplinary medical and psychosocial support staffs’ perceptions of music therapy and its function in a pediatric clinic. The researcher found that the educational in-service was effective as there were significant differences between pre- and posttest survey items concerning goal setting, assessment, and procedural support. Overall, participants had inadequate knowledge of music therapy before the in-service. In a related study, Silverman and Chaput (2011) found a 15-minute in-service to be an effective and efficient technique to educate oncology nurses and gain support for music therapy clinical services and research. These researchers found that participants had limited knowledge about music therapy before the in-service and tended to perceive it as a receptive intervention using recorded music to primarily target relaxation. To the best of the authors’ knowledge, there is no research concerning initial assumptions or expectations of music therapy from adult acute mental health care workers. These data would enable music therapists to design efficient and effective in-services to educate staff, fund additional positions, and increase access to care for mental health service users. Knowledge concerning staff members’ pre-conceived notions and expectations of music therapy may help music therapists to design more efficient and effective in-services and advocate for the profession. As a result of increased advocacy, there may be growth in access to music therapy services for users. Moreover, other healthcare professionals possess valuable knowledge about their unique contexts and service users' needs that could be beneficial for informing the development of new music therapy positions. Therefore, the purpose of this study was to interview adult acute care mental health direct care staff members to understand their assumptions and expectations of music therapy. The guiding research question was: What assumptions and expectations do acute mental health direct care staff have of music therapy treatment for their service users?
staff and group members to determine how they perceived music therapy. Additionally, participants watched videos of themselves in music therapy and provided commentaries. Users and staff were reported to be supportive of music therapy. In a more recent study, after initiating clinical music therapy services, staff working on an adolescent mental health inpatient unit supported and valued music therapy as a complement to talk-based therapy (Patterson et al., 2015). The researchers conducted semi-structured interviews with staff and unit managers, who “unanimously” (p. 4) endorsed music therapy after the researchers implemented 16 sessions. Moreover, the participants noted that music therapy improved their own moods and psitively impacted the ward milieu. In a similar study conducted in an aged care setting, researchers investigated healthcare workers’ (N = 8, including geriatricians, nurses, nurse assistants, speech and language pathologists, physiotherapists, and music therapists) perceptions of a new music therapy program for older adults (Khan, Mohamad Onn Yap, O’Neill, & Moss, 2016). An analysis of semi-structured interviews revealed 1. That music therapy benefitted patients as well as staff, 2. Participants were keen to share ideas concerning how music therapy should be implemented, and 3. A desire for an expansion of music therapy clinical services. Other researchers have found that healthcare professionals who observed and participated in creative arts therapy sessions (Kennedy, Reed, & Wamboldt, 2014) or music therapy sessions (Choi, 1997) with clients were more likely to develop a greater understanding and appreciation of that therapy. However, while there are studies evaluating staff and patient perceptions of music therapy, there remains a lack of literature studying the assumptions and expectations of staff members concerning music therapy before it is implemented. Music therapists establishing new programs experience unique challenges. In consideration of the introduction of music therapy to inter-professional team members, Ledger, Edwards, and Morley (2013) described the resistance and challenges music therapists face in these situations, although they noted that other healthcare professionals developing new services described similar experiences. Other difficulties music therapists can experience when working with other professionals to establish new services can include role ambiguity (Edwards, 2005; Loewy, 2001; O’Neill & Pavlicevic, 2003), isolation (Miles, 2007), and fitting into existing contexts (Edwards, 2005). In a recent action research study exploring how stakeholder input influenced the implementation and sustainability of a new music therapy program in a mental health setting, researchers found that the successful implementation and sustainability of a music therapy program is dependent on the flexibility of the program to the context and culture of the existing health care setting (Bibb, Castle, & McFerran, 2018). For a period of 12 months, researchers conducted two cycles of assessment, action and evaluation where data was collected through interviews with staff members, feedback from clients and attendance in sessions. A number of influential factors were identified as important in the successful implementation of the music therapy program, including: The degree of staff support received; how the program was structured and facilitated; promotion of the program within the service; effective evaluation of the program; and congruence with the existing therapeutic services. As music therapy remains a relatively small field, many mental health professionals may not be aware of how it is implented and how it can benefit participants. Moreover, despite being knowledgeable about the users they serve within their unique contexts, these professionals may have assumptions or expectations about music therapy. In-services can represent a time-efficient, direct, customized, and personable technique to educate others about music therapy. In-services are often utilized to teach people concerning varied topics including non-traditional complementary or integrated healthcare services that may contribute to and augment user care (Silverman, 2015). Music therapists can design and implement specifically tailored educational in-services to increase the awareness of the profession for clinical staff and administrators (Darsie, 2009; Silverman & Chaput, 2011; Silverman,
Method Participants Participants were seven clinical staff members who worked on an acute care mental health unit of a large urban hospital in the southwestern part of the United States. Participants included six nurses with 15 months, 18 months, 9 years, 25 years, 36 years, and 39 years of experience as well as a mental health technician with 13 years of experience. All participants volunteered to take part in the study. As the main research question targeted people who would be familiar with the users and unit, the researchers purposely focused on direct care unit staff who had frequent interactions with users within the contextual parameters of the unit. Thus, administrators, managers, or policy makers at the hospital were not recruited. An original researcher left her position at the hospital after performing interviews and collecting data and requested no further involvement in the project. The first author was responsible for the design and approval of the study. The second author was added to the study after data had been collected. This project was approved by all necessary Institutional Review Boards.
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Manning & Kunkel, 2014). Braun and Clark’s (2006) six phases of thematic analysis involve: 1: Transcribing the interviews and looking for key words and ideas; 2: Generating initial codes; 3: Sorting codes into themes and collating coded data with themes; 4: Reviewing and refining themes; 5: Refining themes; and 6: Explaining themes. First, recorded interviews were transcribed. This was followed by the repeated reading of each transcript, “looking for key words, trends, themes, or ideas in the data” (Guest, MacQueen, & Namey, 2012, p. 8). The second phase of data analysis centered on generating initial codes which were then matched to the relevant data extracts. This ensured that a multitude of potential themes or patterns were coded. The third phase involved “sorting the different codes into potential themes and collating all the relevant coded data extracts within the identified themes” (Braun & Clarke, 2006, p. 89). Thematic maps were used throughout the analytic process in order to facilitate the researchers’ conceptualization of the “relationship between codes, between themes, and between different levels of themes” (Braun & Clarke, 2006, p. 89). The themes were then reviewed during the fourth phase of analysis, wherein some themes were collapsed or further differentiated. At this stage, it was important for there to be “clear and identifiable distinctions between themes” (Braun & Clarke, 2006, p. 90). The themes were further refined in the fifth phase. The sixth phase focused on explaining the meanings, assumptions, and implications of each theme to ensure that “interpretations are supported by actual data” (Guest et al., 2012, p. 12). The authors identified and established code categories and themes during repeated readings of the data, but not prior to these readings (Atkinson & Hammersley, 1998). Throughout the analytic processes, the researchers focused on the explicit content of participants’ narratives (Braun & Clarke, 2006; Hoskyns, 2016; Riessman, 2008) and used an inductive approach to identify themes from transcribed data, wherein initial codes were directly linked to the data but were not driven by the researchers’ prior assumptions concerning relationships among or within data. This approach allowed the researchers to focus on identifying semantic themes whereby “themes are identified within the explicit or surface meanings of the data” (Braun & Clarke, 2006, p. 85).
Procedure The researchers used semi-structured interviews (Corbin & Strauss, 2015) consisting of pre-determined questions as there is currently a lack of existing research and theories to draw upon to appropriately investigate the research question. Questions from the semi-structured interview were initially developed by the first author and then modified by the original researcher (who had left her position) as well as a graduate level music therapy class (see Appendix A). To encourage participants to speak freely, the researchers were flexible with the organization of the questions during the semi-structured interviews. Interviews lasted from approximately 10 to 30-min and were conducted individually. After the process of reviewing the seven interview transcripts, the principal investigator found no additional patterns or new codes were emerging from the data and data collection was discontinued due to thematic saturation (O’Reilly & Parker, 2012). All participants volunteered to take part in the study and, after the researchers explained the study, signed informed consent forms. Interviews were video and audio recorded, transcribed, read by the researchers, sent to participants for member checking, and returned to the researchers. During the interviews, the interviewer took notes concerning participants’ statements. The purpose of these notes was to develop follow-up questions for additional depth and the refinement of subsequent questions during the interviews but these notes were not included in data analyses. During the interviews, the interviewer was active and engaged as evidenced by asking participants to elaborate on statements and engaging them in detailed conversations in an attempt to deeply understand their assumptions and expectations. Participants did not receive payment for their participation nor did they comment on the emerging themes. Authors’ lens and preconceptions At the onset of data analyses, the first author had over 15 years of music therapy and mental health clinical experience in the United States and the second author had seven years of similar experience in Australia. Both authors are active clinicians, educators, and researchers, specializing in adult acute mental health care. Primarily grounded in a cognitive behavioral orientation, the first author used an educational approach to music therapy (Silverman, 2015) to augment users’ illness management and recovery knowledge and skills. This approach was derived from psychoeducational and cognitive behavioral literature so service users would better understand, be aware of, and manage their illnesses. The second author adopts a humanistic and resource-oriented (Rolvsjord, 2010) approach to mental health care practice, that privileges lived experience and collaboration with people in music therapy to best address their needs. Through a large grounded theory study (Bibb & McFerran, 2018), the second author identified a new concept, termed ‘musical recovery’, that provides a framework for understanding peoples’ changing relationships with music during mental health recovery. As it would be impossible to separate those experiences from the researchers’ ways of knowing and interpretations, data elucidation within the current study was informed and shaped by these ongoing clinical, educational and research experiences.
Trustworthiness The researchers independently reviewed all transcriptions, generated initial codes, reviewed and refined codes, organized codes into categories, created initial themes, reviewed and refined themes, defined themes with supportive thematic statements, and provided relevant examples from the data transcriptions. They interacted regularly via live videoconferencing and email throughout the six phases of thematic analysis to ensure trustworthiness. These interactions provided opportunities for reflexive dialogue (Stige, Malterud, & Midtgarden, 2009). Member checking was utilized after data were transcribed for the purpose of ensuring the accuracy of the information gathered. However, as the data indicated that participants were not familiar with music therapy, the researchers did not ask them to comment on emerging themes or results. In an attempt to augment credibility and further understand the data, the first researcher presented the study and results to a graduate level music therapy class during a qualitative data module. These students worked in groups of two or three and collaboratively read through transcripts, asked for additional clarification concerning some data, made suggestions to improve clarity, and verified codes, examples, and themes. To ensure trustworthiness, the researchers had a separate researcher, who has published numerous articles in refereed journals but was not part of the current investigation, review the transcripts, initial codes, themes, and examples of data that supported themes. This reviewer supported the research results. During the identification of emerging themes and comparing and contrasting the independent results, the researchers were guided by the interplay between the client, the music, and the music therapist
Qualitative analysis The researchers created epochés before data analysis in an attempt to recognize any preconceptions or expectations. After a preliminary reading of the transcripts, the researchers met via videoconference to discuss data analysis. Based upon participants’ knowledge of music therapy, the lack of depth within the transcripts, and the exploratory nature of the study, the researchers decided to analyze data using Braun and Clark’s (2006) six phases of thematic analysis. Other researchers have suggested that thematic analysis is an appropriate data analysis technique in exploratory interpretivist studies (Hoskyns, 2016; 96
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(Bruscia, 2014). Bruscia’s model provided a framework with which to conceptualize the data in relation to the research questions. Although the initial jargon differed, emerging themes tended to fit into these broad categories and thus the framework noting that music therapy is comprised of the client, the therapist, and the music. These critical areas guided the emerging themes to be congruent with an existing contextualization of music therapy.
We have some groups, but we don’t have just so many groups, and so they’re not all so fulfilling…So they need stimulation. (JR) The patients are constantly complaining about being bored… (RW) Subtheme: perceptions of the appropriate service user ‘type’ Six participants made reference to the ‘type’ of service user that they thought may or may not benefit from music therapy. Four of the six participants noted that the acuity of a person’s mental state and their symptoms were deciding factors. They noted that users who were psychotic would be inappropriate for music therapy, as they could be unpredictable (JR and MN), upset (MN), out of control (MN), agitated (MN) and aggressive (MN). MN believed that in order for the music therapy group process to work, the environment needed to be safe and this safety may be jeopardized if users with unpredictable behaviors were included in the group. There was a perception that users needed to be stable (NC) in order to benefit from music therapy. NC noted that if users were in a good place and ready to discharge, then participation in music therapy could be a really good thing. In contrast, RW and GM believed that all types (GM) of people with mental illness could benefit from music therapy. For GM, this was with the exception of users who were frustrated, as the increased stimuli that music added had the potential to make them worse. The potential risk of music overstimulating people was also mentioned by DP who believed that for users who are psychotic and already having a lot of internal stimuli, music therapy would be the last thing they [would] need. Despite his/her beliefs about the inappropriate nature of including psychotic users in music therapy, MN concluded that attendance should be based on an individual basis where the music therapist would need to evaluate each case.
Results The following section describes the results of the study derived from the analysis responding to the main research question underpinning this study: What assumptions and expectations do acute mental health care staff have of music therapy treatment for their service users? Findings of the seven interviews are presented through five main themes which have been placed under headings adopted from Bruscia (2014)’s framework articulating music therapy as comprising of the client, the therapist and the music. An additional heading, ‘the context’ has also been included in an attempt to represent the broader context outside of the music therapy program. This interpretation of the data demonstrates the way these participants perceived music therapy in an acute mental health setting in relation to: 1) the client – potential benefits to service users, perceptions of the appropriate service user ‘type;’ 2) the music therapist – unawareness of the music therapy as an established profession with required training and skills; 3) the music – types of music ideal for therapeutic impact; 4) music therapy – treatment expectations; and 5) the context – music therapy would augment and complement existing psychosocial treatment programming. Despite having considerable clinical experience and being knowledgeable about their users within the unique contextual parameters of acute mental health care, participants tended to lack understanding of music therapy and its role in an acute mental health setting. Words spoken directly by participants are italicized to function as examples of the raw data relating to each theme. We also note that participants in this study refer to the people they work with as “patients” rather than mental health service users (which has been used in previous sections of this paper), which may be due to being situated within a hospital context in the United States. Furthermore, Bruscia (2014) referred to the service user as “client.” Although we acknowledge that adopting a different term for “mental health service users” in this section may create some inconsistencies for the reader, we wished to represent the participants’ own words as accurately as possible, while also (for the remainder of the results section) represent mental health service users in a way which is congruent with the person-centered, recovery-based framework in which we work (Fairchild & Bibb, 2016).
…maybe the psychotic ones? Like, the ones who are at the extreme end, like, psychotic ones? Somebody who is actively agitated, you know? Somebody who is very upset because in their mind, they have no time to listen to music… so those kinds of patients would not be appropriate… (MN) …if they’re not open to it, you know, maybe they’re not ready to do that yet. Then, you know, if they’re not stabilized, then I can see that not working for them. (NC) Theme 2: the music therapist Subtheme: unawareness of music therapy as an established profession with required training and skills
Theme: the client
Six participants discussed the skills and training they thought were essential for a music therapist practicing in a mental health setting. In relation to training, one participant (KC) stated that a Masters in Music Therapy was necessary, while others believed a music therapist should have a degree in music (MN) and may have either have gone to music school or attained certification as an audiologist (DP). One participant (GM) noted that a music therapist would need some level of training but was unsure what this training would be. Certain music related skills were mentioned by participants that were perceived as being essential for a music therapist, including the ability to play at least one instrument (DP), have knowledge in music (RW), being familiar with a repertoire of various genres of music (GM), and having a solid background in a variety of different modalities of music (JR). Other skills relating to the mental health setting were mentioned by three participants including, a basic understanding of diagnosis and certain behaviors (JR), the clinical aspects of the mental disorders (RW) and some psychiatric-type experience (DP).
Subtheme: potential benefits to service users Four participants believed that music therapy could benefit service users by providing a space for relaxation. These participants spoke about the calming effect (MN and DP) of music on users which could provide [them] a sense of peace (RW) away from the stressors in their lives (MN). There was also a perception that participation in music therapy could decrease anxiety (RW) and agitation (RW and MN) in users and sooth[e] them (KC). In addition, four participants mentioned the potential for music therapy to motivate service users. DP explained that music might encourage someone who is very withdrawn and not participating in anything else on the unit to begin to participate. GM offered an example of previously observing users who were depressed and tended to isolate, who then engaged in a music activity that was able to draw them out. Finally, two participants perceived music therapy as a way of improving a user’s mood. Music was described as evoking ‘these feelings’, this feel good thing (MN), being uplifting (MN) and a way to evoke positive energy for clients or put a smile on a depressed person’s face (RW).
I’m sure they would have to have some level of training. I’m not sure what it exactly would… be required to be music therapist, but I’m certain that they would have to have some various levels of 97
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training…And I would hope that a music therapist would have a repertoire of various genres of music. (GM)
…talent shows and things like that where people could express their musical talents, and their other talents as well…to interact with them. To find out their likes…in music and to see, you know, just their assessment of the individual and what they would be dealing with. (GM)
I guess they’d have all the skills that our other therapists have. Except they would have knowledge in music as well…they’d have to- to know the clinical aspects of the mental disorders. I guess couple that with… you know, the arts of music? So they would have the science and the arts? (RW)
…it would be an expressive mode of their ability to communicate when they perhaps cannot communicate through words or action. (JR)
Theme 3: the music
… music therapy, and the patients pretty much we would dim the light…they would dim the lights and let the patients pretty much meditate, listen to the music… (KC)
Subtheme: types of music ideal for therapeutic impact Some participants commented on the type of music that might be used in music therapy. Two participants placed importance on using soothing (MN), calm (KC) and not depressing (KC) music. Suggestions such as classical, new age…or anything that involves nature (MN) or sounds of the ocean and rain (KC) were made that were perceived as embodying these qualities. One participant (MN) noted that the music should not involve words while another (NC) stated that the music doesn’t have to be just instruments as it could be words that are helpful to patients in the songs. Three participants made reference to the personal nature of music preference and noted that the type of music used in sessions could depend on the patient (GM), the needs of the population (NC), their diagnosis (MN) and what genre of music they would prefer (GM).
Theme 5: the broader context Subtheme: music therapy would augment and complement existing psychosocial treatment programming Participants were asked if they thought music therapy would complement the existing therapeutic program at the facility. Responses to this question were grouped in relation to the perceived similarities and differences between music therapy and the existing therapeutic program. Five participants thought music therapy would complement the existing program. For example, MN stated that music therapy is no different from everything else. It’s just another way of providing therapy for the patients in this time. While DP described music therapy as just being pretty much the same as the existing program, stating we’re all going for the same goal right? In contrast, one participant (JR) described music therapy as being different to the existing program due to the nonthreatening nature of music which does not rely on users’ verbal abilities. JR elaborated on this idea by stating, music doesn’t do anything to you, it doesn’t pin you in the corner [and] it doesn’t point fingers at you to produce. JR believed the existing therapy groups in the hospital relied heavily on a person’s verbal abilities as opposed to [their] expressive abilities and therefore thought that music therapy could offer service users a different form of expression.
…soft, calm, jazz or… you know, just any music that’s kind of calming to the patients. Quiet, slow. Not anything depressing, I just think that’s what they use, pretty much. Something soft, calm…even use the ocean. You know, the sounds of the ocean and rain, and, different you know, rain drops and different, you know sounds like that…I think it was more soft music, if I’m not mistaken. Or something that, you know, that’s calming to the patients. (KC) …but anything that is classical or like, like new-age or…anything that involves nature, I think has a calming effect. It works in the background…But for some other patients, they may say, “Hey, I want this kind of music,” or…but then, so you’re going to have people who want this or that, but then we can’t cater to everybody, like individually…It should just be music, just like the background?…See, that’s what I was thinking about, too, maybe we tailor the music to their diagnosis, you know? Like if you’re depressed and we need this specific kind of music…we’ll tell them, “Hey, so we’re going to play this music for a certain period of time and say, ten, thirty minutes or so – tell me what you think about it.” Ah, the music that’s played shouldn’t have lyrics in it. (MN)
I just think it’ll enhance it because one, we need more programming, period. And, why not have it be a fun one? (DP) I would like to see it more than probably one time a week. So, I think that music’s very beneficial, so…I see them as being complementary, I guess…I think it would be seen as a positive part of the day, and… When people would have something to look forward to, they’re generally more calm. And, I think overall, behaviorally, it would be a better atmosphere…augment in a beneficial way…So, I’m all for it…I think for the most part our general population would enjoy- enjoy something like that. (RW)
Theme 4: music therapy Subtheme: treatment expectations
Discussion There was diversity in the definition of music therapy offered by participants. One participant (JR) described music therapy as a mode to communicate for service users who cannot communicate through words or action. Two other participants (DP and RW) defined music therapy as an opportunity for participation, describing it as something to participate in (DP). DP also eluded to the potential for clients to have positive experiences through participation in music therapy stating, it helps people who don’t think they have a musical talent [and] makes them feel like at least for that moment they do. Musical talent was also mentioned by GM, in the sense that music therapy may include talent shows where people could express their musical talents. GM also suggested that music therapy could involve the assessment of service users by interacting with them and determining their talents and areas that they might be interested in. Finally, KC described music therapy as a means of meditation while listening to music and playing music that is calming.
Recognizing that other health professionals possess valuable knowledge about their context and service users' needs and the importance of interdisciplinary treatment teams (Twyford & Watson, 2008), the purpose of this investigation was to understand acute care mental health workers’ assumptions and expectations of music therapy. Thematic analysis of individually conducted semi-structured interviews with seven staff members working on an acute care mental health unit revealed that participants supported and perceived music therapy as potentially beneficial for the users and as a complementary psychosocial treatment. However, participants tended to have little understanding of what exactly music therapy was, the types of users who might benefit from it, the training of music therapists, and the music used within music therapy. Emerging themes can provide a framework for information to be included within music therapy educational in98
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respect or appreciation for music therapy. From the results of the current investigation, it seemed that the other professionals supported the potential addition of music therapy to their treatment milieu as they anticipated it would be a benefit to their users despite being familiar with music therapy. It is interesting these positive expectations of music therapy are consistent with other interpretivist music therapy studies (Khan et al., 2016; Patterson et al., 2015) but inconsistent with results from objectivist studies (Braswell et al., 1989; McGinty, 1980; Oppenheim, 1987). Perhaps the incongruencies of the various studies were resultant of the types of data and mixed-methods inquiry might more holistically understand data sets. Implications for clinical practice include specific information that can expediently educate staff members about music therapy. Staff members require information concerning the types of service users applicable for music therapy, the types of music used in music therapy, the training and skills of qualified music therapists, and how music therapy might fit within the existing educational, therapeutic, and psychosocial treatment programming. Due to the heightened needs of the service users on acute care mental health units, staff members need to understand that music therapy typically functions as a complementary and integrative therapy as opposed to an alternative therapy. This information could be presented during in-services, with brochures, or via email. Finally, encouraging staff to attend and participate in music therapy sessions with users may result in a better understanding and appreciation of the profession. Previous research investigating mental health professionals’ opinions of music therapy and other creative art therapies indicated that health professionals who observe and participate in creative arts therapy sessions (Kennedy et al., 2014) or music therapy sessions (Choi, 1997) with clients are more likely to develop a greater understanding and appreciation of that therapy. Limitations of the study include a number of homogenetic factors, including the limited number of participants, who were mostly nurses. Administrators, managers, physicians, policy makers, social workers, and other staff members might have different perspectives. The results of this study are also limited to an acute care mental health unit without music therapy. Staff members who have worked with qualified music therapists would likely have differing perspectives and experiences. Moreover, this study was conducted in a single mental health unit in an urban southwestern area of the United States, thus limiting applicability of results. Another limitation was the follow-up questions during the interviews. As the person who conducted the interviews resigned from their position at the hospital, the researchers did not have access to these notes and therefore could not include them in data analyses. However, participants’ responses to the follow-up questions were in the transcripts and therefore included within analyses. Although the researchers created epochés before data analysis in an attempt to recognize any preconceptions or expectations, results are also limited by the researchers’ interpretations of the data. This study is contextually based in the authors’ perspectives and experiences which inevitably influenced the interpretation of the data. Researchers who practice from different frameworks or who are not as familiar with mental health settings might have understood the data differently. Finally, although the two researchers were from different countries, the socio-cultural contexts dominated by western ideology of these countries tend to be more similar than different and therefore the analysis of data was also influenced by these cultural contexts. Suggestions for future research include mixed methods approaches to use and merge qualitative and quantitative data. By comparing and contrasting the inferences that result from combining multiple worldviews, a more thorough understanding of the perceptions and expectations of music therapy may be gained (Creswell & Tashakkori, 2007; Greene, 2007). Interviewing non-music therapists who have music therapy experience could also produce interesting results that may be helpful for increasing access to care, music therapy referrals, and facilitating advocacy efforts. Studying how a brief educational in-
services. Participants’ perceptions of the types of users who may be appropriate for music therapy tended to center around the unique contextual parameters of acute care mental health. In the United States mental health system, users who have psychotic symptoms are typically not hospitalized on acute care units as they require greater degrees of supervision: Acute care units are separate as there are other specialized units for people who have more severe symptoms and need additional supervision. Although not ideal, the reality is that sometimes users with psychotic symptoms are hospitalized on acute care units when no beds are available on longer-term units. This creates a challenging dynamic for staff as the acute care unit is not designed for people who have psychotic symptoms. This issue emerged when participants discussed perceptions of who may benefit from music therapy, as participants noted that users exhibiting symptoms of psychosis (aggressive or out of control behaviors and responding to internal stimuli) may not be appropriate for music therapy. While service users who require greater supervision due to their symptoms can certainly still benefit from music therapy treatment, it will likely have to be structured in a different manner (i.e., greater structure where the focus is on engaging users in a grounded and reality-based music therapy experience [Wheeler, 1983]) than music therapy for users on an acute care unit (wherein there may be less structure in the intervention and the clinical focus concerns illness management and recovery). Only one participant described music therapy as an alternative means of expression and communication for service users in their hospital. This was apparent in their way of defining music therapy (Theme 4: Music Therapy) and the perception of how music therapy could complement the existing therapeutic treatment program (Theme 5: The Broader Context). In previous research studies that explored staff’s understanding of music therapy in health settings (Khan et al., 2016; Tsiris, Dives & Prince, 2014), participants identified the unique role of music therapy as an opportunity for expression and communication for clients as one of the main benefits of music therapy. The majority of participants in the current study, however, were seemingly unaware of how music therapy could add to their existing program, only noting its benefit as another activity to encourage user participation. Had participants in the current study already experienced music therapy in their workplace or received education prior to being interviewed in the research study, results may have depicted more realistic ideas concerning the distinctive role of music therapy in this setting. While only one participant specifically identified a music therapy degree (in this case, a graduate level degree) was necessary to practice, participants’ assumptions of the skills and training required of a music therapist tended to be inconsistent. From these results, it seems that staff were unaware of specific music therapy academic programs and accompanying curricula. As six of the participants had nursing degrees and were thus likely familiar with the importance of academic and clinical training and professional certification, it is interesting that the nurses did not mention these factors. Only one participant articulated that music skills would be required to be a music therapist. This result is congruent with Silverman and Chaput (2011), who found that oncology nurses tended to believe music therapy is primarily comprised of recorded music before receiving a brief educational in-service. Interestingly, the participants did not mention how lyrics within songs might be used to target therapeutic or educational objectives. Participants did not specifically identify improvisation, lyric discussion, or songwriting as music therapy interventions despite these being commonly used in the United States (Silverman, 2007). Although some participants acknowledged the importance of music preference, participants seemed to identify music therapy as a more passive and receptive intervention wherein relaxing music would be used to calm users. In a previous study, Choi (1997) noted that other researchers (Braswell, Decuir, & Jacobs, 1989; McGinty, 1980; Oppenheim, 1987) found other professionals had what might be considered a lack of 99
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service may impact perceptions and expectations would also help refine educational material and determine the effectiveness of its delivery. It would also be interesting to study administrators’ perceptions as they may be responsible for allocating financial resources for which to hire music therapists. There remains a lack of literature indicating what non-music therapy mental healthcare workers know about the field. Given that other healthcare professionals have considerable knowledge about their contexts and the users they serve, the purpose of this study was to understand acute care mental healthcare workers’ assumptions and expectations of music therapy. Although participants supported the idea of music therapy and perceived it as complementary to existing psychosocial treatment programming and beneficial for users, they tended to have a lack of knowledge about the music used and the training of music therapists. Emerging themes can provide a framework for information to be included within music therapy educational inservices. Future research using all data types and research paradigms is warranted as it may ultimately be used to enhance advocacy efforts and increase access to services for people with mental health disorders.
of a new music therapy program in a mental health service. Mental Health Review Journal manuscript submitted for publication. Bibb, J., & McFerran, K. S. (2018). Musical recovery: The role of group singing in regaining healthy relationships with music to promote mental health recovery. Nordic Journal of Music Therapy.. http://dx.doi.org/10.1080/080981131.2018.1432676. Braswell, C., Decuir, A., & Jacobs, K. (1989). Job satisfaction among music therapists. Journal of Music Therapy, 26, 2–17. http://dx.doi.org/10.1093/jmt/26.1.2. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77–101. http://dx.doi.org/10.1191/1478088706qp063oa. Bruscia, K. E. (2014). Defining music therapy (3rd ed.). Gilsum, NH: Barcelona Publishers. Choi, B. C. (1997). Professional and patient attitudes about the relevance of music therapy as a treatment modality in NAMT approved psychiatric hospitals. Journal of Music Therapy, 34(4), 277–292. http://dx.doi.org/10.1093/jmt/34.4.277. Corbin, J., & Strauss, A. (2015). Basics of qualitative research: Techniques and procedures for developing grounded theory (4th ed.). Washington, DC: Sage. Creswell, J. W., & Tashakkori, A. (2007). Exploring the nature of research questions in mixed methods research. Journal of Mixed Methods Research, 1(3), 207–211. http:// dx.doi.org/10.1177/1558689807302814. Darsie, E. (2009). Interdisciplinary team members’ perceptions of the role of music therapy in a pediatric outpatient clinic. Music Therapy Perspectives, 27, 48–54. Edwards, J. (2005). A reflection on the music therapist’s role in developing a program in a children’s hospital. Music Therapy Perspectives, 23, 36–44. Fairchild, R., & Bibb, J. (2016). Representing people in music therapy research and practice: A balancing act. Voices: A World Forum for Music Therapy, 16(3), http://dx. doi.org/10.15845/voices.v16i3.878. Greene, J. (2007). Mixed methods in social inquiry. San Francisco, CA: Jossey-Bass. Guest, G., MacQueen, K. M., & Namey, E. (2012). Applied thematic analysis. Thousand Oaks, CA: Sage. Hoskyns, S. (1988). Studying group music therapy with adult offenders: Research in progress. Psychology of Music, 16, 25–41. Hoskyns, S. (2016). Thematic analysis. In B. L. Wheeler, & K. Murphy (Eds.). Music therapy research (pp. 563–569). (3rd ed.). Dallas, TX: Barcelona. Kennedy, H., Reed, K., & Wamboldt, M. Z. (2014). Staff perceptions of complementary and alternative therapy integration into a child and adolescent psychiatry program. The Arts in Psychotherapy, 41(1), 21–26. Khan, W. U., Mohamad Onn Yap, I. A., O’Neill, D., & Moss, H. (2016). Perceptions of music therapy for older people among healthcare professionals. Medical Humanities, 42, 52–56. http://dx.doi.org/10.1136/medhum-2015-010778. Ledger, A., Edwards, J., & Morley, M. (2013). A change management perspective on the introduction of music therapy to interprofessional teams. Journal of Health Organization and Management, 27, 714–732. http://dx.doi.org/10.1108/JHOM-112011-0119. Loewy, J. V. (2001). Building bridges in team centred care. Australian Journal of Music Therapy, 12, 3–12. Manning, J., & Kunkel, A. (2014). Researching interpersonal relationships: Qualitative methods, studies and analysis. Thousand Oaks, CA: Sage. McGinty, J. K. (1980). Survey of duties and responsibilities of current music therapy positions. Journal of Music Therapy, 17, 148–166. http://dx.doi.org/10.1093/jmt/17. 3.148. Miles, L. (2007). A life of music therapy: Working together and in isolation. Voices: A World Forum for Music Therapy, 7(3) Retrieved from https://voices.no/index.php/ voices/article/view/552/413. O’Neill, N., & Pavlicevic, M. (2003). What am I doing here? Exploring a role for music therapy with children undergoing bone marrow transplantation at Great Ormond Street Hospital, London. British Journal of Music Therapy, 17, 8–16. Oppenheim, L. (1987). Factors related to occupational stress or burnout among music therapists. Journal of Music Therapy, 24(2), 97–106. http://dx.doi.org/10.1093/jmt/ 24.2.97. O’Reilly, M., & Parker, N. (2012). ‘Unsatisfactory saturation': A critical exploration of the notion of saturated sample sizes in qualitative research. Qualitative Research, 13, 190–197. Patterson, S., Duhig, M., Darbyshire, C., Counsel, R., Higgins, N., & Williams, I. (2015). Implementing music therapy on an adolescent inpatient unit: A mixed-methods evaluation of acceptability, experience of participation and perceived impact. Australasian Psychiatry, 1–5. http://dx.doi.org/10.1177/1039856215592320. Riessman, C. K. (2008). Narrative methods for the human sciences. Thousand Oaks, CA: Sage. Rolvsjord, R. (2010). Resource-oriented music therapy in mental health care. Gilsum, NH: Barcelona Publishers. Silverman, M. J. (2007). Evaluating current trends in psychiatric music therapy: A descriptive analysis. Journal of Music Therapy, 44, 388–414. Silverman, M. J. (2015). Music therapy in mental health for illness management and recovery. New York: Oxford University Press. Silverman, M. J., & Chaput, J. (2011). The effect of a music therapy in-service on perceptions of oncology nursing staff. Music Therapy Perspectives, 29, 74–77. Stige, B., Malterud, K., & Midtgarden, T. (2009). Toward an agenda for evaluation of qualitative research. Qualitative Health Research, 19, 1504–1516. http://dx.doi.org/ 10.1177/1049732309348501. Tsiris, G., Dives, T., & Prince, G. (2014). Music therapy: Evaluation of staff perceptions at St Christopher’s Hospice. European Journal of Palliative Care, 21(2), 72–75. Twyford, K., & Watson, T. (Eds.). (2008). Integrated team working: Music therapy as part of transdisciplinary and collaborative approaches. Philadelphia: Jessica Kingsley. Wheeler, B. L. (1983). A psychotherapeutic classification of music therapy practices: A continuum of procedures. Music Therapy Perspectives, 1(2), 8–12. http://dx.doi.org/ 10.1093/mtp/1.2.8.
Appendix A Semi-Structured Interview Questions Demographic questions for context: 1. What is your occupation and role at the facility? 2. Please describe your current years of experience. How long have your worked in psychiatric settings? 3. Do you have prior experience with music therapy (MT)? If yes, please explain. Explain goal of gaining understanding in terms of designing an effective in-service… Music therapy specific questions: 4. How might you define MT (specific to mental health patients on your acute care unit)? 5. What type of academic training, qualification, clinical training and skills, and experience do you think a Board-Certified MT might have? 6. What might MT look like on your unit? What interventions might a music therapist utilize with acute mental health patients? What might patients be expected to do in MT? 7. What type of music do you think a music therapist might use? 8. What types of clinical objectives might MT be used to address with patients on your unit? 9. Do you think MT will benefit your patients? If so, how? If not, why? 10. How might MT clinical objectives compliment or be dissimilar to clinical objectives from other psychotherapeutic/psychoeducational programming? 11. How might MT uniquely contribute to the needs of the patients on the unit? 12. How might MT augment existing treatment on this unit and contribute to the overall treatment programming for your patients? 13. Are there certain types of patients who may or may not be appropriate for MT groups? Please explain. 14. Please describe any skepticism and/or stereotypes you think treatment team members may have about MT. 15. Do you have questions? If so, please ask. References American Music Therapy Association (2017). A descriptive statistical profile of the 2016 AMTA membership. Silver Spring, MD: Author. Atkinson, P., & Hammersley, M. (1998). Ethnography and participant observation. In N. K. Denzin, & Y. S. Lincoln (Eds.). Strategies of qualitative inquiry (pp. 110–136). Thousand Oaks, CA: Sage. Bibb, J., Castle, D., & McFerran, K. S. (2018). Stakeholder input into the implementation
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Contents lists available at ScienceDirect
The Arts in Psychotherapy journal homepage: www.elsevier.com/locate/artspsycho
Research Article
Acute care mental health workers’ assumptions and expectations of music therapy: A qualitative investigation
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Michael J. Silvermana, , Jennifer Bibbb a b
University of Minnesota, USA University of Melbourne, Australia
A R T I C LE I N FO
A B S T R A C T
Keywords: Music therapy Staff Perceptions Expectations Acute care Mental health Qualitative
A small number of papers indicate that music therapists are interested in how their work is perceived by other healthcare professionals. The research reported in this paper examined assumptions and expectations of music therapy by mental health professionals in order to understand better how music therapists might use effective strategies to empower greater knowledge of their practice and services. We conducted semi-structured interviews with seven clinical staff members of an acute mental health facility that did not have music therapy. Data were analyzed via the six phases of thematic analysis. Member checking and trustworthiness were also used. Guided by the interplay between the user, music, and music therapist that conceptualizes music therapy, we identified five emerging themes concerning assumptions and expectations of music therapy: 1) the client – potential benefits to service users, perceptions of the appropriate service user ‘type;’ 2) the music therapist – unawareness of the music therapy as an established profession with required training and skills; 3) the music – types of music ideal for therapeutic impact; 4) music therapy – treatment expectations; and 5) the context – music therapy would augment and complement existing psychosocial treatment programming. Participants tended to be unfamiliar with most aspects of music therapy and continued education and advocacy are warranted. Emerging themes can provide a framework for information to be included within educational in-services. Suggestions for future research, limitations, and implications for music therapists are provided.
Introduction Although a high percentage of music therapists practice in mental health settings in the United States (AMTA, 2017), there remains a need for additional services to increase access to care. Potentially hindering the development of additional music therapy services, many non-music therapy mental health care workers have limited knowledge about the profession. A small number of papers indicate that music therapists are interested in how their work is perceived by other healthcare professionals. In order to address this gap in the literature, the research reported in this paper examined assumptions and expectations of music therapy by mental health professionals in order to understand better how music therapists might use effective strategies to empower greater knowledge of their practice and services. Literature review Music therapy remains a relatively small profession and many related health care providers may not be aware of the training music
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Corresponding author. E-mail address: [email protected] (M.J. Silverman).
https://doi.org/10.1016/j.aip.2018.05.002 Received 31 October 2017; Received in revised form 7 April 2018; Accepted 9 May 2018 Available online 09 May 2018 0197-4556/ © 2018 Elsevier Ltd. All rights reserved.
therapists receive, the populations music therapists serve, how interventions target clinical objectives, and supporting research. This lack of knowledge may adversely impact people’s perceptions of the field, expectations for treatment, and subsequent access to music therapy treatment for mental health service users (henceforth “users”). For example, if staff members on a mental health unit are unaware of the field and supporting literature, they may not encourage administrators to hire music therapists. Even if music therapy is available as a psychosocial service but the unit staff are unaware of exactly what it is and can do for users, the workers may not recommend that users attend music therapy sessions or provide music therapy referrals. Thus, as collaborative and integrated members of the treatment team (Twyford & Watson, 2008), staff members’ assumptions and expectations of music therapy are consequential and warrant scientific investigation. There is a small research base reporting staff members’ perceptions of music therapy. Hoskyns (1988) published one of the first of these studies and included both staff and service users to obtain a more holistic perspective. In this investigation, the researcher provided group-based music therapy for adult offenders and briefly interviewed
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2015). Increased awareness via education and advocacy can potentially result in additional positions, an increase in referrals and access to care, and additional support for music therapy that may encourage users to attend sessions. However, there is a lack of research concerning what information should be included within music therapy in-services. To date, there is limited published literature concerning staff members’ knowledge of, assumptions, or expectations of music therapy prior to in-service training, observation, or direct experience. Some of these data can be found in music therapy literature wherein pretests were used to assess baseline levels of knowledge before an in-service was provided. For example, in a study using pre- and posttests, Darsie (2009) examined interdisciplinary medical and psychosocial support staffs’ perceptions of music therapy and its function in a pediatric clinic. The researcher found that the educational in-service was effective as there were significant differences between pre- and posttest survey items concerning goal setting, assessment, and procedural support. Overall, participants had inadequate knowledge of music therapy before the in-service. In a related study, Silverman and Chaput (2011) found a 15-minute in-service to be an effective and efficient technique to educate oncology nurses and gain support for music therapy clinical services and research. These researchers found that participants had limited knowledge about music therapy before the in-service and tended to perceive it as a receptive intervention using recorded music to primarily target relaxation. To the best of the authors’ knowledge, there is no research concerning initial assumptions or expectations of music therapy from adult acute mental health care workers. These data would enable music therapists to design efficient and effective in-services to educate staff, fund additional positions, and increase access to care for mental health service users. Knowledge concerning staff members’ pre-conceived notions and expectations of music therapy may help music therapists to design more efficient and effective in-services and advocate for the profession. As a result of increased advocacy, there may be growth in access to music therapy services for users. Moreover, other healthcare professionals possess valuable knowledge about their unique contexts and service users' needs that could be beneficial for informing the development of new music therapy positions. Therefore, the purpose of this study was to interview adult acute care mental health direct care staff members to understand their assumptions and expectations of music therapy. The guiding research question was: What assumptions and expectations do acute mental health direct care staff have of music therapy treatment for their service users?
staff and group members to determine how they perceived music therapy. Additionally, participants watched videos of themselves in music therapy and provided commentaries. Users and staff were reported to be supportive of music therapy. In a more recent study, after initiating clinical music therapy services, staff working on an adolescent mental health inpatient unit supported and valued music therapy as a complement to talk-based therapy (Patterson et al., 2015). The researchers conducted semi-structured interviews with staff and unit managers, who “unanimously” (p. 4) endorsed music therapy after the researchers implemented 16 sessions. Moreover, the participants noted that music therapy improved their own moods and psitively impacted the ward milieu. In a similar study conducted in an aged care setting, researchers investigated healthcare workers’ (N = 8, including geriatricians, nurses, nurse assistants, speech and language pathologists, physiotherapists, and music therapists) perceptions of a new music therapy program for older adults (Khan, Mohamad Onn Yap, O’Neill, & Moss, 2016). An analysis of semi-structured interviews revealed 1. That music therapy benefitted patients as well as staff, 2. Participants were keen to share ideas concerning how music therapy should be implemented, and 3. A desire for an expansion of music therapy clinical services. Other researchers have found that healthcare professionals who observed and participated in creative arts therapy sessions (Kennedy, Reed, & Wamboldt, 2014) or music therapy sessions (Choi, 1997) with clients were more likely to develop a greater understanding and appreciation of that therapy. However, while there are studies evaluating staff and patient perceptions of music therapy, there remains a lack of literature studying the assumptions and expectations of staff members concerning music therapy before it is implemented. Music therapists establishing new programs experience unique challenges. In consideration of the introduction of music therapy to inter-professional team members, Ledger, Edwards, and Morley (2013) described the resistance and challenges music therapists face in these situations, although they noted that other healthcare professionals developing new services described similar experiences. Other difficulties music therapists can experience when working with other professionals to establish new services can include role ambiguity (Edwards, 2005; Loewy, 2001; O’Neill & Pavlicevic, 2003), isolation (Miles, 2007), and fitting into existing contexts (Edwards, 2005). In a recent action research study exploring how stakeholder input influenced the implementation and sustainability of a new music therapy program in a mental health setting, researchers found that the successful implementation and sustainability of a music therapy program is dependent on the flexibility of the program to the context and culture of the existing health care setting (Bibb, Castle, & McFerran, 2018). For a period of 12 months, researchers conducted two cycles of assessment, action and evaluation where data was collected through interviews with staff members, feedback from clients and attendance in sessions. A number of influential factors were identified as important in the successful implementation of the music therapy program, including: The degree of staff support received; how the program was structured and facilitated; promotion of the program within the service; effective evaluation of the program; and congruence with the existing therapeutic services. As music therapy remains a relatively small field, many mental health professionals may not be aware of how it is implented and how it can benefit participants. Moreover, despite being knowledgeable about the users they serve within their unique contexts, these professionals may have assumptions or expectations about music therapy. In-services can represent a time-efficient, direct, customized, and personable technique to educate others about music therapy. In-services are often utilized to teach people concerning varied topics including non-traditional complementary or integrated healthcare services that may contribute to and augment user care (Silverman, 2015). Music therapists can design and implement specifically tailored educational in-services to increase the awareness of the profession for clinical staff and administrators (Darsie, 2009; Silverman & Chaput, 2011; Silverman,
Method Participants Participants were seven clinical staff members who worked on an acute care mental health unit of a large urban hospital in the southwestern part of the United States. Participants included six nurses with 15 months, 18 months, 9 years, 25 years, 36 years, and 39 years of experience as well as a mental health technician with 13 years of experience. All participants volunteered to take part in the study. As the main research question targeted people who would be familiar with the users and unit, the researchers purposely focused on direct care unit staff who had frequent interactions with users within the contextual parameters of the unit. Thus, administrators, managers, or policy makers at the hospital were not recruited. An original researcher left her position at the hospital after performing interviews and collecting data and requested no further involvement in the project. The first author was responsible for the design and approval of the study. The second author was added to the study after data had been collected. This project was approved by all necessary Institutional Review Boards.
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Manning & Kunkel, 2014). Braun and Clark’s (2006) six phases of thematic analysis involve: 1: Transcribing the interviews and looking for key words and ideas; 2: Generating initial codes; 3: Sorting codes into themes and collating coded data with themes; 4: Reviewing and refining themes; 5: Refining themes; and 6: Explaining themes. First, recorded interviews were transcribed. This was followed by the repeated reading of each transcript, “looking for key words, trends, themes, or ideas in the data” (Guest, MacQueen, & Namey, 2012, p. 8). The second phase of data analysis centered on generating initial codes which were then matched to the relevant data extracts. This ensured that a multitude of potential themes or patterns were coded. The third phase involved “sorting the different codes into potential themes and collating all the relevant coded data extracts within the identified themes” (Braun & Clarke, 2006, p. 89). Thematic maps were used throughout the analytic process in order to facilitate the researchers’ conceptualization of the “relationship between codes, between themes, and between different levels of themes” (Braun & Clarke, 2006, p. 89). The themes were then reviewed during the fourth phase of analysis, wherein some themes were collapsed or further differentiated. At this stage, it was important for there to be “clear and identifiable distinctions between themes” (Braun & Clarke, 2006, p. 90). The themes were further refined in the fifth phase. The sixth phase focused on explaining the meanings, assumptions, and implications of each theme to ensure that “interpretations are supported by actual data” (Guest et al., 2012, p. 12). The authors identified and established code categories and themes during repeated readings of the data, but not prior to these readings (Atkinson & Hammersley, 1998). Throughout the analytic processes, the researchers focused on the explicit content of participants’ narratives (Braun & Clarke, 2006; Hoskyns, 2016; Riessman, 2008) and used an inductive approach to identify themes from transcribed data, wherein initial codes were directly linked to the data but were not driven by the researchers’ prior assumptions concerning relationships among or within data. This approach allowed the researchers to focus on identifying semantic themes whereby “themes are identified within the explicit or surface meanings of the data” (Braun & Clarke, 2006, p. 85).
Procedure The researchers used semi-structured interviews (Corbin & Strauss, 2015) consisting of pre-determined questions as there is currently a lack of existing research and theories to draw upon to appropriately investigate the research question. Questions from the semi-structured interview were initially developed by the first author and then modified by the original researcher (who had left her position) as well as a graduate level music therapy class (see Appendix A). To encourage participants to speak freely, the researchers were flexible with the organization of the questions during the semi-structured interviews. Interviews lasted from approximately 10 to 30-min and were conducted individually. After the process of reviewing the seven interview transcripts, the principal investigator found no additional patterns or new codes were emerging from the data and data collection was discontinued due to thematic saturation (O’Reilly & Parker, 2012). All participants volunteered to take part in the study and, after the researchers explained the study, signed informed consent forms. Interviews were video and audio recorded, transcribed, read by the researchers, sent to participants for member checking, and returned to the researchers. During the interviews, the interviewer took notes concerning participants’ statements. The purpose of these notes was to develop follow-up questions for additional depth and the refinement of subsequent questions during the interviews but these notes were not included in data analyses. During the interviews, the interviewer was active and engaged as evidenced by asking participants to elaborate on statements and engaging them in detailed conversations in an attempt to deeply understand their assumptions and expectations. Participants did not receive payment for their participation nor did they comment on the emerging themes. Authors’ lens and preconceptions At the onset of data analyses, the first author had over 15 years of music therapy and mental health clinical experience in the United States and the second author had seven years of similar experience in Australia. Both authors are active clinicians, educators, and researchers, specializing in adult acute mental health care. Primarily grounded in a cognitive behavioral orientation, the first author used an educational approach to music therapy (Silverman, 2015) to augment users’ illness management and recovery knowledge and skills. This approach was derived from psychoeducational and cognitive behavioral literature so service users would better understand, be aware of, and manage their illnesses. The second author adopts a humanistic and resource-oriented (Rolvsjord, 2010) approach to mental health care practice, that privileges lived experience and collaboration with people in music therapy to best address their needs. Through a large grounded theory study (Bibb & McFerran, 2018), the second author identified a new concept, termed ‘musical recovery’, that provides a framework for understanding peoples’ changing relationships with music during mental health recovery. As it would be impossible to separate those experiences from the researchers’ ways of knowing and interpretations, data elucidation within the current study was informed and shaped by these ongoing clinical, educational and research experiences.
Trustworthiness The researchers independently reviewed all transcriptions, generated initial codes, reviewed and refined codes, organized codes into categories, created initial themes, reviewed and refined themes, defined themes with supportive thematic statements, and provided relevant examples from the data transcriptions. They interacted regularly via live videoconferencing and email throughout the six phases of thematic analysis to ensure trustworthiness. These interactions provided opportunities for reflexive dialogue (Stige, Malterud, & Midtgarden, 2009). Member checking was utilized after data were transcribed for the purpose of ensuring the accuracy of the information gathered. However, as the data indicated that participants were not familiar with music therapy, the researchers did not ask them to comment on emerging themes or results. In an attempt to augment credibility and further understand the data, the first researcher presented the study and results to a graduate level music therapy class during a qualitative data module. These students worked in groups of two or three and collaboratively read through transcripts, asked for additional clarification concerning some data, made suggestions to improve clarity, and verified codes, examples, and themes. To ensure trustworthiness, the researchers had a separate researcher, who has published numerous articles in refereed journals but was not part of the current investigation, review the transcripts, initial codes, themes, and examples of data that supported themes. This reviewer supported the research results. During the identification of emerging themes and comparing and contrasting the independent results, the researchers were guided by the interplay between the client, the music, and the music therapist
Qualitative analysis The researchers created epochés before data analysis in an attempt to recognize any preconceptions or expectations. After a preliminary reading of the transcripts, the researchers met via videoconference to discuss data analysis. Based upon participants’ knowledge of music therapy, the lack of depth within the transcripts, and the exploratory nature of the study, the researchers decided to analyze data using Braun and Clark’s (2006) six phases of thematic analysis. Other researchers have suggested that thematic analysis is an appropriate data analysis technique in exploratory interpretivist studies (Hoskyns, 2016; 96
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(Bruscia, 2014). Bruscia’s model provided a framework with which to conceptualize the data in relation to the research questions. Although the initial jargon differed, emerging themes tended to fit into these broad categories and thus the framework noting that music therapy is comprised of the client, the therapist, and the music. These critical areas guided the emerging themes to be congruent with an existing contextualization of music therapy.
We have some groups, but we don’t have just so many groups, and so they’re not all so fulfilling…So they need stimulation. (JR) The patients are constantly complaining about being bored… (RW) Subtheme: perceptions of the appropriate service user ‘type’ Six participants made reference to the ‘type’ of service user that they thought may or may not benefit from music therapy. Four of the six participants noted that the acuity of a person’s mental state and their symptoms were deciding factors. They noted that users who were psychotic would be inappropriate for music therapy, as they could be unpredictable (JR and MN), upset (MN), out of control (MN), agitated (MN) and aggressive (MN). MN believed that in order for the music therapy group process to work, the environment needed to be safe and this safety may be jeopardized if users with unpredictable behaviors were included in the group. There was a perception that users needed to be stable (NC) in order to benefit from music therapy. NC noted that if users were in a good place and ready to discharge, then participation in music therapy could be a really good thing. In contrast, RW and GM believed that all types (GM) of people with mental illness could benefit from music therapy. For GM, this was with the exception of users who were frustrated, as the increased stimuli that music added had the potential to make them worse. The potential risk of music overstimulating people was also mentioned by DP who believed that for users who are psychotic and already having a lot of internal stimuli, music therapy would be the last thing they [would] need. Despite his/her beliefs about the inappropriate nature of including psychotic users in music therapy, MN concluded that attendance should be based on an individual basis where the music therapist would need to evaluate each case.
Results The following section describes the results of the study derived from the analysis responding to the main research question underpinning this study: What assumptions and expectations do acute mental health care staff have of music therapy treatment for their service users? Findings of the seven interviews are presented through five main themes which have been placed under headings adopted from Bruscia (2014)’s framework articulating music therapy as comprising of the client, the therapist and the music. An additional heading, ‘the context’ has also been included in an attempt to represent the broader context outside of the music therapy program. This interpretation of the data demonstrates the way these participants perceived music therapy in an acute mental health setting in relation to: 1) the client – potential benefits to service users, perceptions of the appropriate service user ‘type;’ 2) the music therapist – unawareness of the music therapy as an established profession with required training and skills; 3) the music – types of music ideal for therapeutic impact; 4) music therapy – treatment expectations; and 5) the context – music therapy would augment and complement existing psychosocial treatment programming. Despite having considerable clinical experience and being knowledgeable about their users within the unique contextual parameters of acute mental health care, participants tended to lack understanding of music therapy and its role in an acute mental health setting. Words spoken directly by participants are italicized to function as examples of the raw data relating to each theme. We also note that participants in this study refer to the people they work with as “patients” rather than mental health service users (which has been used in previous sections of this paper), which may be due to being situated within a hospital context in the United States. Furthermore, Bruscia (2014) referred to the service user as “client.” Although we acknowledge that adopting a different term for “mental health service users” in this section may create some inconsistencies for the reader, we wished to represent the participants’ own words as accurately as possible, while also (for the remainder of the results section) represent mental health service users in a way which is congruent with the person-centered, recovery-based framework in which we work (Fairchild & Bibb, 2016).
…maybe the psychotic ones? Like, the ones who are at the extreme end, like, psychotic ones? Somebody who is actively agitated, you know? Somebody who is very upset because in their mind, they have no time to listen to music… so those kinds of patients would not be appropriate… (MN) …if they’re not open to it, you know, maybe they’re not ready to do that yet. Then, you know, if they’re not stabilized, then I can see that not working for them. (NC) Theme 2: the music therapist Subtheme: unawareness of music therapy as an established profession with required training and skills
Theme: the client
Six participants discussed the skills and training they thought were essential for a music therapist practicing in a mental health setting. In relation to training, one participant (KC) stated that a Masters in Music Therapy was necessary, while others believed a music therapist should have a degree in music (MN) and may have either have gone to music school or attained certification as an audiologist (DP). One participant (GM) noted that a music therapist would need some level of training but was unsure what this training would be. Certain music related skills were mentioned by participants that were perceived as being essential for a music therapist, including the ability to play at least one instrument (DP), have knowledge in music (RW), being familiar with a repertoire of various genres of music (GM), and having a solid background in a variety of different modalities of music (JR). Other skills relating to the mental health setting were mentioned by three participants including, a basic understanding of diagnosis and certain behaviors (JR), the clinical aspects of the mental disorders (RW) and some psychiatric-type experience (DP).
Subtheme: potential benefits to service users Four participants believed that music therapy could benefit service users by providing a space for relaxation. These participants spoke about the calming effect (MN and DP) of music on users which could provide [them] a sense of peace (RW) away from the stressors in their lives (MN). There was also a perception that participation in music therapy could decrease anxiety (RW) and agitation (RW and MN) in users and sooth[e] them (KC). In addition, four participants mentioned the potential for music therapy to motivate service users. DP explained that music might encourage someone who is very withdrawn and not participating in anything else on the unit to begin to participate. GM offered an example of previously observing users who were depressed and tended to isolate, who then engaged in a music activity that was able to draw them out. Finally, two participants perceived music therapy as a way of improving a user’s mood. Music was described as evoking ‘these feelings’, this feel good thing (MN), being uplifting (MN) and a way to evoke positive energy for clients or put a smile on a depressed person’s face (RW).
I’m sure they would have to have some level of training. I’m not sure what it exactly would… be required to be music therapist, but I’m certain that they would have to have some various levels of 97
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training…And I would hope that a music therapist would have a repertoire of various genres of music. (GM)
…talent shows and things like that where people could express their musical talents, and their other talents as well…to interact with them. To find out their likes…in music and to see, you know, just their assessment of the individual and what they would be dealing with. (GM)
I guess they’d have all the skills that our other therapists have. Except they would have knowledge in music as well…they’d have to- to know the clinical aspects of the mental disorders. I guess couple that with… you know, the arts of music? So they would have the science and the arts? (RW)
…it would be an expressive mode of their ability to communicate when they perhaps cannot communicate through words or action. (JR)
Theme 3: the music
… music therapy, and the patients pretty much we would dim the light…they would dim the lights and let the patients pretty much meditate, listen to the music… (KC)
Subtheme: types of music ideal for therapeutic impact Some participants commented on the type of music that might be used in music therapy. Two participants placed importance on using soothing (MN), calm (KC) and not depressing (KC) music. Suggestions such as classical, new age…or anything that involves nature (MN) or sounds of the ocean and rain (KC) were made that were perceived as embodying these qualities. One participant (MN) noted that the music should not involve words while another (NC) stated that the music doesn’t have to be just instruments as it could be words that are helpful to patients in the songs. Three participants made reference to the personal nature of music preference and noted that the type of music used in sessions could depend on the patient (GM), the needs of the population (NC), their diagnosis (MN) and what genre of music they would prefer (GM).
Theme 5: the broader context Subtheme: music therapy would augment and complement existing psychosocial treatment programming Participants were asked if they thought music therapy would complement the existing therapeutic program at the facility. Responses to this question were grouped in relation to the perceived similarities and differences between music therapy and the existing therapeutic program. Five participants thought music therapy would complement the existing program. For example, MN stated that music therapy is no different from everything else. It’s just another way of providing therapy for the patients in this time. While DP described music therapy as just being pretty much the same as the existing program, stating we’re all going for the same goal right? In contrast, one participant (JR) described music therapy as being different to the existing program due to the nonthreatening nature of music which does not rely on users’ verbal abilities. JR elaborated on this idea by stating, music doesn’t do anything to you, it doesn’t pin you in the corner [and] it doesn’t point fingers at you to produce. JR believed the existing therapy groups in the hospital relied heavily on a person’s verbal abilities as opposed to [their] expressive abilities and therefore thought that music therapy could offer service users a different form of expression.
…soft, calm, jazz or… you know, just any music that’s kind of calming to the patients. Quiet, slow. Not anything depressing, I just think that’s what they use, pretty much. Something soft, calm…even use the ocean. You know, the sounds of the ocean and rain, and, different you know, rain drops and different, you know sounds like that…I think it was more soft music, if I’m not mistaken. Or something that, you know, that’s calming to the patients. (KC) …but anything that is classical or like, like new-age or…anything that involves nature, I think has a calming effect. It works in the background…But for some other patients, they may say, “Hey, I want this kind of music,” or…but then, so you’re going to have people who want this or that, but then we can’t cater to everybody, like individually…It should just be music, just like the background?…See, that’s what I was thinking about, too, maybe we tailor the music to their diagnosis, you know? Like if you’re depressed and we need this specific kind of music…we’ll tell them, “Hey, so we’re going to play this music for a certain period of time and say, ten, thirty minutes or so – tell me what you think about it.” Ah, the music that’s played shouldn’t have lyrics in it. (MN)
I just think it’ll enhance it because one, we need more programming, period. And, why not have it be a fun one? (DP) I would like to see it more than probably one time a week. So, I think that music’s very beneficial, so…I see them as being complementary, I guess…I think it would be seen as a positive part of the day, and… When people would have something to look forward to, they’re generally more calm. And, I think overall, behaviorally, it would be a better atmosphere…augment in a beneficial way…So, I’m all for it…I think for the most part our general population would enjoy- enjoy something like that. (RW)
Theme 4: music therapy Subtheme: treatment expectations
Discussion There was diversity in the definition of music therapy offered by participants. One participant (JR) described music therapy as a mode to communicate for service users who cannot communicate through words or action. Two other participants (DP and RW) defined music therapy as an opportunity for participation, describing it as something to participate in (DP). DP also eluded to the potential for clients to have positive experiences through participation in music therapy stating, it helps people who don’t think they have a musical talent [and] makes them feel like at least for that moment they do. Musical talent was also mentioned by GM, in the sense that music therapy may include talent shows where people could express their musical talents. GM also suggested that music therapy could involve the assessment of service users by interacting with them and determining their talents and areas that they might be interested in. Finally, KC described music therapy as a means of meditation while listening to music and playing music that is calming.
Recognizing that other health professionals possess valuable knowledge about their context and service users' needs and the importance of interdisciplinary treatment teams (Twyford & Watson, 2008), the purpose of this investigation was to understand acute care mental health workers’ assumptions and expectations of music therapy. Thematic analysis of individually conducted semi-structured interviews with seven staff members working on an acute care mental health unit revealed that participants supported and perceived music therapy as potentially beneficial for the users and as a complementary psychosocial treatment. However, participants tended to have little understanding of what exactly music therapy was, the types of users who might benefit from it, the training of music therapists, and the music used within music therapy. Emerging themes can provide a framework for information to be included within music therapy educational in98
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respect or appreciation for music therapy. From the results of the current investigation, it seemed that the other professionals supported the potential addition of music therapy to their treatment milieu as they anticipated it would be a benefit to their users despite being familiar with music therapy. It is interesting these positive expectations of music therapy are consistent with other interpretivist music therapy studies (Khan et al., 2016; Patterson et al., 2015) but inconsistent with results from objectivist studies (Braswell et al., 1989; McGinty, 1980; Oppenheim, 1987). Perhaps the incongruencies of the various studies were resultant of the types of data and mixed-methods inquiry might more holistically understand data sets. Implications for clinical practice include specific information that can expediently educate staff members about music therapy. Staff members require information concerning the types of service users applicable for music therapy, the types of music used in music therapy, the training and skills of qualified music therapists, and how music therapy might fit within the existing educational, therapeutic, and psychosocial treatment programming. Due to the heightened needs of the service users on acute care mental health units, staff members need to understand that music therapy typically functions as a complementary and integrative therapy as opposed to an alternative therapy. This information could be presented during in-services, with brochures, or via email. Finally, encouraging staff to attend and participate in music therapy sessions with users may result in a better understanding and appreciation of the profession. Previous research investigating mental health professionals’ opinions of music therapy and other creative art therapies indicated that health professionals who observe and participate in creative arts therapy sessions (Kennedy et al., 2014) or music therapy sessions (Choi, 1997) with clients are more likely to develop a greater understanding and appreciation of that therapy. Limitations of the study include a number of homogenetic factors, including the limited number of participants, who were mostly nurses. Administrators, managers, physicians, policy makers, social workers, and other staff members might have different perspectives. The results of this study are also limited to an acute care mental health unit without music therapy. Staff members who have worked with qualified music therapists would likely have differing perspectives and experiences. Moreover, this study was conducted in a single mental health unit in an urban southwestern area of the United States, thus limiting applicability of results. Another limitation was the follow-up questions during the interviews. As the person who conducted the interviews resigned from their position at the hospital, the researchers did not have access to these notes and therefore could not include them in data analyses. However, participants’ responses to the follow-up questions were in the transcripts and therefore included within analyses. Although the researchers created epochés before data analysis in an attempt to recognize any preconceptions or expectations, results are also limited by the researchers’ interpretations of the data. This study is contextually based in the authors’ perspectives and experiences which inevitably influenced the interpretation of the data. Researchers who practice from different frameworks or who are not as familiar with mental health settings might have understood the data differently. Finally, although the two researchers were from different countries, the socio-cultural contexts dominated by western ideology of these countries tend to be more similar than different and therefore the analysis of data was also influenced by these cultural contexts. Suggestions for future research include mixed methods approaches to use and merge qualitative and quantitative data. By comparing and contrasting the inferences that result from combining multiple worldviews, a more thorough understanding of the perceptions and expectations of music therapy may be gained (Creswell & Tashakkori, 2007; Greene, 2007). Interviewing non-music therapists who have music therapy experience could also produce interesting results that may be helpful for increasing access to care, music therapy referrals, and facilitating advocacy efforts. Studying how a brief educational in-
services. Participants’ perceptions of the types of users who may be appropriate for music therapy tended to center around the unique contextual parameters of acute care mental health. In the United States mental health system, users who have psychotic symptoms are typically not hospitalized on acute care units as they require greater degrees of supervision: Acute care units are separate as there are other specialized units for people who have more severe symptoms and need additional supervision. Although not ideal, the reality is that sometimes users with psychotic symptoms are hospitalized on acute care units when no beds are available on longer-term units. This creates a challenging dynamic for staff as the acute care unit is not designed for people who have psychotic symptoms. This issue emerged when participants discussed perceptions of who may benefit from music therapy, as participants noted that users exhibiting symptoms of psychosis (aggressive or out of control behaviors and responding to internal stimuli) may not be appropriate for music therapy. While service users who require greater supervision due to their symptoms can certainly still benefit from music therapy treatment, it will likely have to be structured in a different manner (i.e., greater structure where the focus is on engaging users in a grounded and reality-based music therapy experience [Wheeler, 1983]) than music therapy for users on an acute care unit (wherein there may be less structure in the intervention and the clinical focus concerns illness management and recovery). Only one participant described music therapy as an alternative means of expression and communication for service users in their hospital. This was apparent in their way of defining music therapy (Theme 4: Music Therapy) and the perception of how music therapy could complement the existing therapeutic treatment program (Theme 5: The Broader Context). In previous research studies that explored staff’s understanding of music therapy in health settings (Khan et al., 2016; Tsiris, Dives & Prince, 2014), participants identified the unique role of music therapy as an opportunity for expression and communication for clients as one of the main benefits of music therapy. The majority of participants in the current study, however, were seemingly unaware of how music therapy could add to their existing program, only noting its benefit as another activity to encourage user participation. Had participants in the current study already experienced music therapy in their workplace or received education prior to being interviewed in the research study, results may have depicted more realistic ideas concerning the distinctive role of music therapy in this setting. While only one participant specifically identified a music therapy degree (in this case, a graduate level degree) was necessary to practice, participants’ assumptions of the skills and training required of a music therapist tended to be inconsistent. From these results, it seems that staff were unaware of specific music therapy academic programs and accompanying curricula. As six of the participants had nursing degrees and were thus likely familiar with the importance of academic and clinical training and professional certification, it is interesting that the nurses did not mention these factors. Only one participant articulated that music skills would be required to be a music therapist. This result is congruent with Silverman and Chaput (2011), who found that oncology nurses tended to believe music therapy is primarily comprised of recorded music before receiving a brief educational in-service. Interestingly, the participants did not mention how lyrics within songs might be used to target therapeutic or educational objectives. Participants did not specifically identify improvisation, lyric discussion, or songwriting as music therapy interventions despite these being commonly used in the United States (Silverman, 2007). Although some participants acknowledged the importance of music preference, participants seemed to identify music therapy as a more passive and receptive intervention wherein relaxing music would be used to calm users. In a previous study, Choi (1997) noted that other researchers (Braswell, Decuir, & Jacobs, 1989; McGinty, 1980; Oppenheim, 1987) found other professionals had what might be considered a lack of 99
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service may impact perceptions and expectations would also help refine educational material and determine the effectiveness of its delivery. It would also be interesting to study administrators’ perceptions as they may be responsible for allocating financial resources for which to hire music therapists. There remains a lack of literature indicating what non-music therapy mental healthcare workers know about the field. Given that other healthcare professionals have considerable knowledge about their contexts and the users they serve, the purpose of this study was to understand acute care mental healthcare workers’ assumptions and expectations of music therapy. Although participants supported the idea of music therapy and perceived it as complementary to existing psychosocial treatment programming and beneficial for users, they tended to have a lack of knowledge about the music used and the training of music therapists. Emerging themes can provide a framework for information to be included within music therapy educational inservices. Future research using all data types and research paradigms is warranted as it may ultimately be used to enhance advocacy efforts and increase access to services for people with mental health disorders.
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Appendix A Semi-Structured Interview Questions Demographic questions for context: 1. What is your occupation and role at the facility? 2. Please describe your current years of experience. How long have your worked in psychiatric settings? 3. Do you have prior experience with music therapy (MT)? If yes, please explain. Explain goal of gaining understanding in terms of designing an effective in-service… Music therapy specific questions: 4. How might you define MT (specific to mental health patients on your acute care unit)? 5. What type of academic training, qualification, clinical training and skills, and experience do you think a Board-Certified MT might have? 6. What might MT look like on your unit? What interventions might a music therapist utilize with acute mental health patients? What might patients be expected to do in MT? 7. What type of music do you think a music therapist might use? 8. What types of clinical objectives might MT be used to address with patients on your unit? 9. Do you think MT will benefit your patients? If so, how? If not, why? 10. How might MT clinical objectives compliment or be dissimilar to clinical objectives from other psychotherapeutic/psychoeducational programming? 11. How might MT uniquely contribute to the needs of the patients on the unit? 12. How might MT augment existing treatment on this unit and contribute to the overall treatment programming for your patients? 13. Are there certain types of patients who may or may not be appropriate for MT groups? Please explain. 14. Please describe any skepticism and/or stereotypes you think treatment team members may have about MT. 15. Do you have questions? If so, please ask. References American Music Therapy Association (2017). A descriptive statistical profile of the 2016 AMTA membership. Silver Spring, MD: Author. Atkinson, P., & Hammersley, M. (1998). Ethnography and participant observation. In N. K. Denzin, & Y. S. Lincoln (Eds.). Strategies of qualitative inquiry (pp. 110–136). Thousand Oaks, CA: Sage. Bibb, J., Castle, D., & McFerran, K. S. (2018). Stakeholder input into the implementation
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