Mental health problems are common during youth, with one in 10 young people experiencing depression and anxiety (AIHW, 2007), and over 50% of bi polar and psychotic disorders appearing before the age of 25 (Jablenckey et al., 2000). Austrian youth mental health services have an international reputation for innovation in integrating recovery philosophy with early intervention principles that specifically aim to engage young people as early as possible (Harkin, 2014; NAMI, 2013; Ramon, Healy, & Renouf, 2007). This approach is focused on youth friendly forms of care that offer age appropriate and stigma free engagement for young people aged 12-25 years (McGorry, Bates, & Birchwood, 2013).
Music is highly relevant to young people’s everyday health management. Recent Australian statistics indicate that young people listen to music for an average of 18 hours per week (Papinczak, Dingle, Stoyanov, Hides, & Zelenko, 2015) and many identify music as their preferred activity (North, Hargreaves, & O'Neil, 2000). Research details how much of young people’s music engagement is linked to unconscious everyday health maintenance, where young people manage their mood by listening to particular songs that alter, enhance or sustain emotional states (Dillman Carpentier et al., 2008; Saarikallio & Erkkila, 2007). Although researchers have pursued the idea that particular genres might be problematic in causing mental health problems, findings consistently illustrate how the user’s existing relationship with songs provides the emotional agent, not the style of music itself (Jiang, Rickson, & Jiang, 2016; North & Hargreaves, 2006). In fact, for many young people, commitment to particular genres or styles of music can offer means for social connection by sharing and uniting around preferences and their associated styles, values and lifestyle choices (Rentfrow, McDonald, & Oldmeadow, 2009). These processes can contribute to healthy development as young people form a sense of identity and belonging to peer groups (North et al., 2000).
Experiences of mental illness can interfere with critical processes of mood regulation (Leibenluft, 2011), social connection (MacDonald et al., 2004; Macdonad, Sauer, Howie, & Albiston, 2005), and identity construction (Carless, 2008). For many young people, music provides an important resource for tackling these challenges, and this may explain why music use often peaks during times of mental health problems (Thomson, Reece, & Di Benedetto, 2014). For others, mental distress can impact the ability to use music to effectively manage their wellbeing (McFerran & Saarikallio, 2014). Research illustrates how music can become part of unhelpful illness behaviours such as rumination or self-harm (Cheong-Clinch, 2013), evoke painful memories (Bibb & McFerran, 2018), or feed into social isolation when seen as an alternative to friendships (Hense, McFerran, & McGorry, 2014). However, these same studies highlight that when engaged in music encounters carefully facilitated by professionals, young people can reconnect with the health promoting aspects of music.
Music therapy has a strong clinical history (Eyre, 2013; Rolvsjord, 2010; Wigram & Jos de Backer, 1999) and research base in mental health care (Gold, Voracek, & Wigram, 2004; Grocke, Bloch, & Castle, 2009; Maratos, Gold, Wang, & Crawford, 2009; Mossler, Chan, Heldal, & Gold, 2005). In 2016, 37% of Australian Registered Music Therapists reported working in mental health care and 48% with young people (Jack et al., 2016). In youth mental health specifically, music therapists describe how otherwise isolated young people can connect and build a sense of belonging through a shared interest in music (McFerran, 2010). Sessions can be used to explore self-concept, where building music skills or engaging in shared music making can foster health-based identities and meaningful social participation (Hense & McFerran, 2017; Solli, 2014). Young people can also use music therapy to explore the relationship between music and their mental health (Cheong-Clinch, 2013), re-establish healthy relationships with music (Bibb, 2016), and build capacities for everyday music uses beyond therapy (Hense, 2014). These processes often focus on, and nurture young people’s strengths and personal interests, and music therapists are increasingly articulating the relevance of these processes to recovery principles in mental health care (Grocke, Bloch, & Castle, 2008; McCaffrey, Edwards, Fannon, 2011; Solli, Rolvsjord, & Borg, 2013).
Music appears highly relevant to youth mental health care yet establishing and maintaining music therapy programmes in existing mental health systems can be challenging. Some music therapists report resistance from other staff when working in interprofessional contexts, leading to experiences of isolation (Bybee, 2017) and role ambiguity (O'Neill & Pavlicevic, 2003). This can impact the ongoing success of music therapy programmes that rely on referrals from other clinicians (Ledger, Edwards, & Morley, 2013). Although literature in this area has primarily focused on music therapists’ experiences of working within multidisciplinary contexts, research in adult populations does suggest that other clinicians’ views of music therapy depend upon their discipline and degree of exposure to music therapy (Choi, 1997; Purvis, 2010). These findings suggest that in order to move past interdisciplinary barriers, music therapists may benefit from further investigating what other clinicians know about their work and how they feel about their services.
Little research has been conducted exploring clinicians’ perceptions of music therapy within youth mental health services, or the ways in which music therapy may best be promoted to support programmes in this context. To address this gap, an exploratory study was designed at a service with an existing music therapy programme; examining how clinicians’ perceptions of music therapy may impact referrals, and whether specific strategies for promoting music therapy could be identified. The study aimed to address the following question: How do clinicians’ perceptions of music therapy influence referrals to the music therapy programme at a youth mental health service? A set of research intentions guided the method of inquiry.
· What factors influence clinicians’ decisions to refer a young person to music therapy?
· What patterns can be interpreted between rates of referral and other factors in responses? (such as profession or contact with the music therapist).
· What strategies would be helpful for supporting referrals to music therapy?
The study took place in a youth mental health service that cares for approximately 800 young people annually. This was also the work place of the author. The service includes a 12-bed in-patient unit for short stays of approximately 10 days, as well as an extensive out-patient service offering care for up to two years across two different sites. Young people access the service for support with mood disorders, psychosis, personality disorders, as well as co-occurring substance use disorders.
The music therapy programme, including both individual and group-based sessions, has been offered one day per week for over 10 years. The music therapist is a member of the psychosocial team which includes social workers, occupational therapists, an art therapist, and teachers, offering a variety of social, vocational, and creative interventions. She has been a practising Registered Music Therapist for the last eight years, offering both individual and group-based sessions. Her approach is influenced by resource-oriented music therapy (Rolvsjord, 2010) as well as community music therapy principles (Stige & Aaro, 2012) that align with the strength-based and collaborative philosophy of the service. Young people can be referred to music therapy from all sites of the service. Anecdotally, despite the large number of staff involved, referrals tend to come from the same relatively small collection of clinicians. Past strategies used by the music therapist to inform staff about music therapy and the programme at the service included; small in-service offerings to different teams, presentations at clinical review meetings, posters, flyers, musical performances, and emails. The nature of the facility means that many staff work part time or across different sites, making it difficult for the music therapist to access everyone in her one day per week role.
During the development of this project, advice from the service’s research advisory panel was that data collection processes needed to be brief and easily accessible for the busy clinical staff. So, the initial plan to engage staff in qualitative interviews was abandoned in place of an online survey designed to solicit feedback from as many clinicians of the youth mental health service as possible. The service’s research advisory panel also provided specific feedback about the subsequent development of the survey. Ethical approval was obtained through the governing Human Research Ethics Review Board as a quality assurance project with permission for publication of the findings (QA2016038).
Participants and recruitment.
The study was open to all clinicians working across the three sites of the youth mental health service and included mental health nurses, occupational therapists, psychiatrists, psychologists, an art therapist, and social workers, totalling 137 staff. Participation was voluntary and anonymous. An invitation and link to the survey was emailed to staff by a third party, three times across a four-week period.
Qualitative and quantitative data were collected from both open and closed survey questions. Open ended questions were used to solicit clinicians’ perspectives and ideas, and closed questions were used to assess the frequency with which clinicians engage with particular processes relating to referral to music therapy.
An inductive analysis was used, informed by grounded theory (influenced primarily by Charmaz, 2014a). Inductive analysis involves generating codes or categories from raw data rather than testing data according to hypotheses. The purpose of this approach is to allow findings to emerge from the data without the imposition of pre-existing assumptions (Thomas, 2006). Although often used as an approach on its own, inductive analysis also forms the basis of many qualitative analytic methods that extend into more specific strategies depending on the purpose of the research or philosophical orientation.
Grounded theory (Charmaz, 2014a) uses inductive analysis with the purpose of building rather than testing theory. The analytic strategies can also be applied for generating theoretical categories or statements as the final results in what is often termed ‘modified’ grounded theory (Charmaz, 2014b). Where other forms of qualitative analysis focus on description and distillation of the data, grounded theory permits a greater degree of interpretation involving abstraction and constant comparison of data against data (Sandelowski & Barroso, 2003). Although the approach is most commonly used with in-depth interviews, the techniques can be applied to many forms of qualitative and quantitative data (Charmaz, 1996). Grounded theory strategies were chosen for this study because they enabled analysis of patterns in the data, as well as the forming of conceptual interpretations about the relationship between perceptions of music therapy and referrals. Grounded theory typically involves a process of theoretical sampling, where the researcher returns to collect new data to test and develop the emerging theory (Morse, 2007). The small survey design of this study did not allow for theoretical sampling in this traditional sense, and so the data was re-examined using multiple questions in order to challenge initial ideas and concepts. This lack of theoretical sampling was also seen as adequate for the research purpose of forming a set of responses to the research questions, rather than generating a theory.
Data were loaded into an Excel spreadsheet with one row of responses per participant and loaded into NVivo software program for categorisation and comparison. The initial analysis involved coding each open-ended question and grouping common or recurrent codes to form categories. Data were systematically grouped according to each question and any trends in corresponding data were noted. Through this initial process, potential patterns that related to several of the survey questions were identified. It then seemed appropriate to develop emergent research sub-questions to respond to this first wave of analysis and guide a more in-depth analysis of these areas in the data. These questions included:
1) What patterns can be interpreted between clinicians’ descriptions of music therapy and the number of referrals?
2) What patterns can be interpreted between clinicians’ frequency of discussion of music and the number of referrals?
3) What patterns can be interpreted between clinicians’ descriptions of why they refer to music therapy and how often they discuss music with young people?
To investigate the relationship between participants’ descriptions of music therapy and their number of referrals, data were broken down by rates of referrals (0, 1-5, 6-10, more than 10) and each group’s corresponding key themes from their descriptions of music therapy.
A subsequent analysis was conducted to look for any patterns between how often clinicians discuss music with young people and how many young people they have referred to music therapy. Data were grouped according to the frequency of discussion of music (often, sometimes, never), and compared to the corresponding frequency of referrals in each group (0, 1-5, 6-10, more than 10).
A final analysis involved searching for patterns between clinicians’ description of why they would refer to music therapy and how often they discuss music with young people at the service. Here, data were broken into groups based on frequency of discussion of music (never, sometimes, often) and the corresponding themes from descriptions about why clinicians would refer to music therapy were analysed.
The findings were presented to an experienced supervising researcher for feedback at several points across the analytic procedure. This process challenged the author’s interpretations of the material at times and although the nature of the survey meant that the responses in the data were short, depth was achieved through the degree of analytic processing involved.
Twenty six out of 119 staff responded, resulting in a response rate of 21.8%. Two of these indicated they were not in clinical positions and therefore left some irrelevant questions blank. See Table 1 below for a breakdown of participants’ profession.
For the purpose of this paper, results will be presented in a way that addresses the research questions rather than reporting on each survey question individually. Results from the initial round of analysis indicated patterns in only several areas of the data, as detailed in the analysis above. These areas of the findings will now will be presented in response to the emergent research sub-questions. Words in single quotations represent codes from qualitative analysis.
In response to emergent research sub-question 1: What patterns can be interpreted between clinicians’ descriptions of music therapy and the number of referrals? Five people indicated that they had referred more than 10 people to music therapy. This was the only group to describe music therapy as strengths-based, using references to building or using ‘strengths’, in the pursuit of ‘wellbeing’ rather than treatment of illnesses. This was contrasted by descriptions from the eight people who reported never referring to music therapy, who described it as a ‘therapeutic tool’ or made reference to the use of music in health ‘processes’. This group’s descriptions generally appeared more medicalised, with less emphasis on the benefits and more on therapeutic terminology. The remaining 12 participants indicated having referred 1-5 people. Their descriptions of music therapy focused on how music could be used as a ‘strategy in facilitating recovery’ with descriptions of both the process and role of music in dealing with illness. See Table 2.
Breakdown of participant profession.
Descriptions of music therapy according to number of referrals.
Results for emergent research sub-questions 2: What patterns can be interpreted between clinicians’ frequency of discussion of music and the number of referrals? And 3:What patterns can be interpreted between clinicians’ descriptions of why they refer to music therapy and how often they discuss music with young people? have been combined to help build a more meaningful interpretation of the data. See Tables 3 and 4. Five people indicated that they always discuss music with young people, and of these, two had more than 10 referrals and the remaining three had 1-5 referrals. Their reasons for referring indicated having ‘witnessed outcomes’ from music therapy previously or having an ‘understanding’ of how music therapy could support the young person. These answers were the longest and most descriptive of all groups.
Sixteen people indicated that they sometimes discuss music with young people. Five of these had 0 referrals, seven had 1-5, one had 6-10, and 3 had more than 10. All but three of these respondents indicated that at least part of the reason for referral would be if they, the young person or family identified the young person has ‘an interest in music’.
Three out of the four people who indicated that they never speak about music with young people indicated 0 referrals, with the remaining one respondent indicating 1-5 referrals. This group’s reasons for referring appeared limited and beyond this brevity, did not appear to contain any common theme.
Frequency of discussion of music and number of referrals.
Reasons for referral according to frequency of discussion of music.
Clinicians were also asked whether or not they would be interested in attending professional development sessions about music and young people’s mental health. One hundred percent of participants indicated they would like to attend these sessions. Table 5 shows a breakdown of the preference between attending an information session about music therapy and the programme available at the service and/or learning how to integrate music into their own clinical work with young people.
Breakdown of interest in attending professional development seminars about music and young people's mental health.
The purpose of this study was to explore how clinicians’ perceptions of music therapy influence referrals to the music therapy programme at a youth mental health service. The emergent findings showed patterns between clinicians’ descriptions of music therapy and the number of referrals, patterns between clinicians’ frequency of discussion of music and the number of referrals, and patterns between clinicians’ descriptions of why they refer to music therapy and how often they discuss music with young people. These findings will now be discussed.
The relevance of music therapy as a strength-based approach.
Results demonstrate a trend towards higher rates of referrals when the clinician perceives music therapy as a strength-based practice, or as an adjunct in working towards common recovery goals of the service. It is possible that those with an existing strength-based orientation (and vocabulary) may be more amenable to adjunct therapies such as music therapy, or that those who have a greater understanding of how music therapy can support these strength-based recovery goals are more inclined to refer. This finding illustrates clinicians’ support for strengths-based approaches that align with the recovery ethos of the service. Yet the relatively low number of referrals suggests that more clinician’s need to be made aware of the relevance. This finding is congruent with other music therapists’ experiences of lack of understanding of the profession and a constant need to educate their non-music therapy co-workers (Bybee, 2017; Hills, Norman, & Forster, 2000; Ledger et al., 2013).
In an international study investigating music therapists’ experiences of establishing new positions, Ledger et al., (2013) reported that music therapists felt more accepted by other team members when they explicitly aligned their work to the service’s priorities, as well as to other clinicians’ ideas about what music therapy could contribute. There has been growing discourse about the suitability of music therapy to recovery-based mental health services (McCaffrey, Carr, Solli, & Hense, 2018). Research investigating service users’ experiences of music therapy has highlighted the congruence to recovery principles in supporting strengths and identity outside the illness role (Solli, Rolvsjord, & Borg, 2013). Music therapists have also articulated how the practice can contribute to recovery-based services by enacting core principles of collaboration and mutuality (McCaffrey, Edwards, & Fannon, 2011), as well as the fostering of personal meaning and resources (Grocke, Bloch, & Castle, 2009; Rolvsjord, 2010). However, these arguments have primarily been targeted toward the music therapy audience and it may be time to place greater emphasis on educating neighbouring professions. Some music therapists also believe that advertising or ‘marketing’ music therapy within services assists in building existing programmes (Jack et al., 2016). Whilst the benefits of an overall greater understanding of music therapy appears clear, the constant need for music therapists to educate and advertise has been critiqued as a process of workplace oppression where music therapists are marginalised into subordinate roles (Bybee, 2017). Targeting interdisciplinary publications and liaising with workplace systems to take some responsibility for disseminating information to all new staff might be a more empowered approach.
Clinicians as gatekeepers to accessing music therapy.
Based on the findings, referrals to music therapy appear most dependent upon the clinician’s engagement in discussing music with the young person. Those with the highest referrals to music therapy were more likely to discuss music with young people. Their answers suggested a greater understanding of how music might benefit young people’s mental health. Those who only spoke about music ‘sometimes’, indicated a more passive approach to referral by waiting to see if the young person demonstrated some existing interest in music. Whilst structuring a young person’s care around their individual interests aligns with a recovery approach (Davidosn, Tandora, O’Connell, & Lawless, 2009), the inconsistent raising of music with young people suggests the potential role of music in their mental health is often overlooked. These clinicians may be serving as gate keepers by not raising music with young people, denying them the opportunity to demonstrate their interest.
The concept of ‘gatekeeper’ has been frequently applied in studies exploring young people’s access to mental health support (Hunt & Eisenberg, 2010; Rickwood, Deane, Wilson, & Ciarrochi, 2005). In these contexts, gatekeepers are positioned as facilitators in young people’s pathways to care, and can include carers, teachers, and even peers (Kelly, Jorm, & Wright, 2007; Villagrana, 2010). Music therapists are frequently in positions where the success of their programme relies heavily on other clinicians, and so the concept of gatekeeper is more often explored in relation to accessing music therapy within a service. This literature illustrates how music therapists often work to appeal to managers and those in positions of power to support their programme (Ledger et al., 2013), whilst constantly demonstrating the value of their contribution to the team (Choi, 1997; Jack et al., 2017). Edwards (2015) has discussed this approach through a critical feminist lens in which music therapists can be seen as pre-occupied with gaining acceptance to the majority patriarchal view. However, she also acknowledged the reality that, to enable people’s access to music, music therapists must in part at least, conform to systems that demand professional credibility. Within the field of youth mental health particularly, although the concept of ‘getting in’ with a recovery system that espouses egalitarian principles seems paradoxical, gaining recognition with other clinicians and managers can be seen as vital in order to foster young people’s access to music. And so, music therapists may choose to consciously pursue this approach.
Strategies for increasing young people’s access to music therapy.
In this context, young people’s access to music therapy relies heavily on the judgement of other mental health clinicians. Findings from this study illustrate clinicians inconsistent raising of music with young people may impact whether or not music therapy is considered as an option. Whilst it is unlikely that every young person would choose to participate in music therapy, best practice would mean making them aware that this option is available to them. The lack of complete and consistent information sharing suggested in these findings appears consistent with other studies, where young people have been found to request greater access to information about interventions and services available, particularly alternative options (Simmons, Hetrick, & Jorm, 2011; Wisdom, Clarke, & Green, 2006). One strategy going forward would be to advocate for greater sharing of information with young people about all services available to them.
‘Information sharing’ is a familiar concept in youth mental health, where shared decision making between the young person (and family) and clinicians is a core feature of recovery-oriented care (Simmons & Hetrick, 2012). Increasing clinician’s awareness of the need to discuss music in each young person’s care would address young people’s desire for greater access to information, as well as increase exposure to the option of music therapy. Demonstrating the value of including discussions of music into early sessions may facilitate this process.
Young people seeking mental health support have reported concerns about over medicalisation of their experiences and expressed desires for normalcy (Wisdom et al., 2006). Music presents an everyday normal engagement for young people that is central to youth culture (Bennett, 2000). From clinicians’ perspective, actually engaging young people in the service presents one of the major challenges to supporting young people’s mental health recovery (Simmons et al., 2012). It has been detailed how improving rapport in early sessions may facilitate engagement (French, Reardon, & Smith, 2003), and young people report that experiences of connection and commonalities with clinicians can facilitate this rapport building (Wisdom et al., 2006). Assisting clinicians to see how music offers a normalising option for engaging young people in discussions about preferences and interests, but in ways that carry relevance to mental health, could facilitate their willingness to include this topic in early clinical sessions.
The response from participants in this study indicating their interest in attending professional development sessions on music and young people’s mental health is encouraging. Those with the highest referrals to music therapy were more likely to indicate that they would prefer a session on how to use music in their own work with young people, compared to those with lower referrals who tended to prefer information sessions about music therapy itself. These findings suggest that initially increasing referrals may rely most heavily on disseminating information about music therapy to clinicians, whereas increasing young people’s access to the health benefits of music more broadly would be possible through training already interested clinicians in how to use music in their practice.
In-services are frequently used as a means of educating staff cohorts about interdisciplinary services available in workplaces. A study of music therapists working in mental health care in the United States found that 64.8% provided in-services to promote their programmes (Silverman, 2007). Gallagher, Huston, Nelson, Walsh and Steele (2001) examined the process of establishing a new music therapy programme in a palliative care hospital and proposed that in order to build referrals, all new staff participate in music therapy in-services when commencing their employment. Although in-services had been provided in this youth mental health facility, these had been infrequent and not systematically embedded in new staff inductions. Collaborating with managers to establish a regular music therapy in-service for all new clinicians could be beneficial and should include information about music therapy and indications for referral. Periodical workshops could be held to assist clinicians in understanding the relationship between young people and their mental health, and provide strategies for incorporating discussions of music into their own clinical work.
Limitations of the study.
This study offers an initial exploration into interdisciplinary clinicians’ perceptions of music therapy, and as such, cannot be seen to represent generalisable findings. Furthermore, the interpretivist approach taken for this study means that the findings are not intended to be generalisable or replicable. They do, however, offer insights that may be useful for clinicians who are attempting to build a practice in similar settings.
Although the small response rate to the survey is within the typical range for survey participation, it does mean that the findings are likely to represent a particular group of clinicians at the service rather than the complete staff profile. It may be that these clinicians are more interested in or supportive of music therapy, which could explain the very high interest in attending professional development seminars on the topic.
Recommendations for future research.
Future studies should focus on exploring this topic in more depth with clinicians at mental health services. This would be possible through open-ended interviews that allow for emergent conversation and topics. An interview design would also allow for greater exploration of clinicians’ perceptions of music therapy in relation to their own philosophical approach to mental health care and how they feel music therapy might benefit the young people they work with.
Implications for music therapy clinicians.
The findings from this study suggest that in order to have a flourishing programme, music therapists working in mental health contexts need to not only possess all the relevant clinical skills for the job, but also equip themselves with skills required to educate other clinicians about their profession, advertise what they offer, and advocate for support at more systematic levels. Offering in-services to provide information about music therapy programmes as well as more in-depth workshops to build clinicians’ skills in integrating music into their work might best address the issue of referrals as well as young people’s access to music.
This study also shows that, in this service at least, interdisciplinary clinicians appear interested in learning more about music and young people’s mental health. Although sharing information about music therapy might be the fastest way to increase referrals, for some clinicians taking a broader view and supporting them to integrate music into their own work may actually best support young people’s access to music as a mental health resource.
This study highlights the central role that clinicians play in young people’s access to music therapy, and the success of a music therapy service. Findings suggest that increasing clinicians’ understanding about the strength-based aspects of music therapy and how the practice aligns with recovery goals of the service, may increase young people’s opportunities to access music therapy if they choose.
Clinicians may not always overlook music when failing to raise the topic with young people but might instead feel ill-equipped to discuss music in a way that seems meaningful to mental health. Running professional development sessions to up skill clinicians about the relationship between music and mental health, and how to identify those young people who may be indicated for referral to music therapy, could support greater information sharing about the role of music in youth mental health services. Supporting clinicians to integrate music into their discussions with young people would not only serve to increase potential referrals to music therapy but may also increase young people’s awareness of the positive potentials of music in managing mental health, as well as offer several engagement benefits outside of music itself. Although there has been critique of music therapists engaging in these educative processes at the ground level, establishing formal avenues through which this can occur for all new staff, might facilitate more sustainable awareness of music therapy programmes, whilst making services accountable for upskilling their staff about all services available.
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