The utilisation of visual supports within music therapy practice in Australia: Listening and looking

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The utilisation of visual supports within music therapy practice in Australia: Listening and looking

In plain language

For people who find it difficult to communicate, the use of visual supports can be helpful. These visual supports may include schedules, choice boards or first-then cards. Music Therapists have been utilising visual supports within music therapy programs for some time, however there are no known publications on the use of these tools by Australian Registered Music Therapists (RMTs). This article shares the results from a survey on visual supports that was conducted at the Australian Music Therapy Association (AMTA) National Conference in 2018. It was found that RMTs think it is important to take an individualised approach to the utilisation of visual supports within their music therapy practice. They also report that using these tools may be beneficial for clients in easing stress and anxiety, promoting agency, and in supporting communication. The results indicate that additional practitioner research would be valuable to assist us in understanding more about how music therapists are using visual supports and how effective they are for the benefit of their clients.


Abstract

The utilisation of visual supports by music therapists within their practice has existed for some time, as evidenced by intermittent and ad-hoc mentions within published professional reports and spoken presentations. However, scant literature exists on visual supports in music therapy practice, particularly regarding the range of tools used. Due to this apparent but mostly unreported use, the need was identified to investigate the utilisation of visual supports by Registered Music Therapists (RMTs) within Australia. A survey was distributed to RMTs in order to gather data on their reasons for using visual supports, and their targeted population groups. Questions on visual support format, appearance, delivery, and training experiences were also included. Data were collected via hard-copy forms distributed at the Australian Music Therapy Association (AMTA) National Conference in 2018, then entered and analysed using descriptive statistics and thematic analysis. Of the 71 respondents, results showed the majority of RMTs surveyed (98.6%, n=70) have utilised visual supports within their music therapy practice. On investigation, findings from this initial survey suggest that RMTs take an individualised client-centred approach to the utilisation of visual supports within their music therapy practice, and report that using these tools may ease client stress and anxiety, promote client agency, and support client communication. It is recommended that additional practitioner research be undertaken, particularly directed towards the application and effectiveness of visual supports within music therapy, focused on developing a best-practice, evidence-based approach.


Citation

Fuller, A.M., & Short, A E. (2020). The utilisation of visual supports within music therapy practice in Australia: Listening and looking. Australian Journal of Music Therapy. Advance online publication. Retrieved from https://www.austmta.org.au/journal/article/utilisation-visual-supports-within-music-therapy-practice-australia-listening-and


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Date published: October 2020

Background

     Visual supports, such as photos, pictures or other visual materials, have been shown as effective in assisting individuals who have additional communication needs across the expressive and/or receptive modes (Alant, 2017; Kluth, 2010). However, there is a paucity of writings on the use of these tools within the field of music therapy, despite the apparent use, and a gap in the knowledge-base, expertise and research on this practice approach within music therapy has been identified (Gadberry & Sweeney, 2017; McCarthy, 2013). In order to explore this topic, this section begins with broadly addressing the overarching field of Augmentative and Alternative Communication (AAC), followed by focusing on the AAC strategy of using visual supports in the context of practitioner-knowledge.

Augmentative and Alternative Communication (AAC)

     Augmentative and alternative communication (AAC) is an area of practice, primarily in the field of speech pathology (also called speech and language therapy), “that addresses the needs of individuals with significant and complex communication disorders characterized by impairments in speech production and/or comprehension” (American Speech-Language-Hearing Association, 2020, Overview section). While the use of AAC is most commonly directed towards supporting people with a disability, it is increasingly being applied with other population groups, including assisting people at the end of life stage and within aged care (Alant, 2017; Binger & Kent-Walsh, 2010). In the case of individuals who have existing functional speech, AAC systems and devices that ‘augment’ their current communication can be of benefit. For others who have little or no functional speech, AAC can be implemented as an ‘alternative’ communication strategy. AAC may be required as an interim measure for some individuals (e.g. when recovering from surgery), or as a permanent approach for people with an ongoing disability (Beukelman & Mirenda, 2013; Speech Pathology Australia, 2016). An individualised approach is used in best-practice delivery of AAC for individuals with additional communication needs, as the range of potential strategies is extensive, and the needs of individuals are diverse (Visvader, 2013). Figure 1 provides examples of AAC strategies that may be used for assisting people who require additional support with their communication needs.

Figure 1. Examples of Augmentative and Alternative Communication Strategies [Original]

     Surveys of music therapists in the USA, UK and Europe show that training for music therapy students in AAC techniques may be inadequate or omitted, and that there is a need for AAC instruction within professional development programs for practicing music therapists (Gadberry & Sweeney, 2017; McCarthy, 2013). In addition, there is no published academic literature relating to Australian RMTs’ use of AAC within their practice. Anecdotally, it is understood that RMTs often use a ‘total communication’ approach (Bradshaw, 2000; Calliou et al., 2008) whereby a combination of sign-language, gestures, technology devices and visual supports are combined in order to best serve the individual needs of their clients. Via my (author 1) experiences over 20 years (e.g. conferences, observations, practice-experience), I have often noted visual supports being utilised within music therapy across a range of different settings and population groups. For the purpose of this study, the area of visual supports was selected as the focus AAC strategy due to the apparent accepted use of these tools within music therapy practice.

Visual Supports

     Visual supports can take many forms (Figure 2) including visual schedules and developed systems such as the Picture Exchange Communication System (PECS) (Bondy & Frost, 2001). Within music therapy specifically, coded music notation (colours, symbols or other forms of coding) and printed song lyrics may also be considered to be visual supports (Gadberry, 2011).

     For the purpose of this study, the visual materials integrated into these supports included photos, illustrations, line-drawings or text. Materials may be hard-copy (free-hand or printed), and often laminated, or they may be digital versions including technology (Hahna et al, 2012). Photo examples of visual supports utilised within music therapy practice are provided (see Appendix A). In the music therapy practice setting, the foundational basis for decisions made regarding the implementation of visual supports is commonly built on by the RMT with a ‘what works’ approach, and typically, such knowledge comes from experience.

Figure 2. Examples of Visual Support Tools Utilised Within Music Therapy Practice [Original]

     Researcher Practice-Knowledge. My practice-knowledge and pragmatic experience have shaped this project as is common in applied research. Researchers across a wide range of health applications have seen the benefits of using practice-knowledge to shape and inform their projects. Higgs et al (2004), within their book Developing Practice Knowledge for Health Professionals, address the areas of physiotherapy, occupational therapy, medicine and nursing, arguing the importance of systematically blending practice-knowledge and research. Others such as Benner (2001) and the Joanna Briggs Institute (Jordan et al., 2018) from the field of nursing have developed models of patient care that place an importance on practice-knowledge, and encourage researchers in the field to include the practitioner voice within the progressive phases of their research. For the purpose of this paper I have drawn on these aforementioned writings, and those of Wolcott (2009) in including the voice of the researcher, and Bazeley (2018) in thinking of the mixed methods researcher as a bricoleur, “one who pieces together emergent solutions to a puzzle” (p. 97), while working with the understanding that researcher involvement affects the outcomes.

     My early employment working with children with Autism Spectrum Disorder (ASD) fostered experiences and work-based training in using visual strategies with clients. Further positions included opportunities to work with families with complex needs, which led to developing and implementing visual supports such as a flip-book, photo/illustration cards and song-boards. Additional ongoing use of visual supports for the benefit of clients and students has included contexts of specific music therapy projects and master’s level teaching (Fuller & McLeod, 2019). See Appendix B for a more detailed explanation of my journey in utilising visual supports. In light of my knowledge and experience, the current study was approached from an interest in the journeys of other music therapists in the way they have also developed methods for using visual supports based on practice-knowledge in their work. In systematically gathering this information, I have endeavoured via this study to assist RMTs in extending their skills and understanding of the use of visual supports within their music therapy work, for the benefit of their clients. In order to address this aim, the following six key research questions were developed, with a focus on the approach taken by RMTs within their music therapy practice.

  1. 1. Why are visual supports being utilised?
  2. 2. Who are visual supports being used with?
  3. 3. What types of visual supports are being used?
  4. 4. What do these visual supports look like?
  5. 5. How are visual supports being delivered within sessions?
  6. 6. Has training in using visual supports been undertaken?

     Based on the relevant literature as previously outlined, and my developing practice-knowledge, a survey was designed and administered in order to further understand the experiences, knowledge and ideas of current RMTs in Australia. This was expected to contribute to the national and international knowledge base, and shed new light on approaches and benefits of this practice.

Method

     Within this mixed methods pragmatic approach (Patton, 2015; Sheperis et al., 2018), a survey was chosen as a non-invasive and convenient way to obtain information from practicing RMTs without adding further research burden to their everyday work (Fink, 2017). Data collection took place using approved hard copy forms at the Australian Music Therapy Association (AMTA) National Conference (September 2018, Sydney). An implied consent strategy was used for all participants (Western Sydney University HREC REDI: H12885), and a convenient sample process was undertaken, with the key inclusion criteria for participants being that they were a current RMT. Verbal announcements were made by the conference convenor inviting all RMTs to participate, regardless of their interest in the topic. A definition of AAC, and more specifically visual supports, was provided at the start of the survey for use by respondents in order to assist with consistency of understanding the focus topic. The data collection period was finalised after the conference completion.

     The six key research questions were addressed by developing a survey (see Appendix C) which was informed by ideas, lists and terminology from the relevant published surveys from the field of music therapy (Gadberry, 2011; McCarthy et al., 2008). Quantitative and qualitative data were collected through the survey, consisting of tick-box and short answer contextual questions. An online survey was considered but abandoned due to technology challenges that could possibly deter RMTs from participating in the survey at the conference.

Data Analysis

     An integrated mixed methods analysis approach was undertaken on the data collected, focused towards capturing and interpreting the voice of the participant, in this case the individual RMT (Bazeley, 2018; Creswell, 2018). Both the quantitative and qualitative data analyses were conducted concurrently in order to capture the essence of the responses, given the participants were asked to fill in tick-boxes and short answers within the one integrated survey. The statistical binary data collected were analysed using descriptive statistics (Huck, 2012; Mertens, 2020), with a thematic analysis of the short answer responses (Nowell et al., 2017). After a period of familiarisation and engagement with the data, first and second cycle processes were carried out, chosen based on the emergent conceptual framework for this research (Saldaña, 2015).

     First Cycle Coding. For every response to the open-ended questions, codes in the form of short in vivo phrases were assigned to symbolically ascribe an essence-capturing attribute for that portion of the data. During initial coding, a splitting approach was used whereby short phrases from each participant response were retrieved, providing smaller codable moments, until repetition of a response was noted. The data were then broken into discrete parts and closely examined and compared. In vivo codes that demonstrated similarities were grouped and dissimilar codes were set aside as provisional emerging categories until a pattern of similarities was detected which would allow for the formation of a new group (Corbin & Strauss, 2015).

     Second Cycle Coding. Reanalysing data then took place using a focused coding approach in order to develop the most salient categories and themes in relation to the project questions. A narrative was developed through linking each of the emerged themes which were written as gerunds (an ‘ing’ word) in order to capture the mostly ‘active’ nature of the therapeutic medium. Relevant statements were captured from all survey responses in order to address the six key research questions (Saldaña, 2015).

     An independent researcher not connected with the project audited the coding process and confirmed the structure of the themes. The writing of analytic memos was employed in order for the researcher to reflect on participant responses and write on the emerging patterns, categories and themes. (Corbin & Strauss, 2015; Nowell et al., 2017).

Results

     The 175 RMTs attending this national conference represented 35.5% of active RMTs residing in Australia. This survey response rate was 40.5% of conference attendees. Of the 71 respondents, the mode for ‘length of time as an RMT’ was 10-20 years, and for ‘highest level of education in music therapy’ was master’s, as outlined in Figures 3 and 4.

     Seventy survey respondents indicated ‘yes’ to using visual supports within their music therapy practice, based on the provided definition (98.6%). Given this high rate of affirmative response, no correlations between demographic information and the use of visual supports within practice were evident. The data collected via this survey were analysed in order to address the six key research questions.

Figure 3. Respondents: Years of Experience in Music Therapy

Figure 4. Respondents: Highest Level of Education in Music Therapy

Question 1: Why Do RMTs Use Visual Supports Within Their Music Therapy Practice?

     In addressing this first question, the majority of responses were taken from survey sections regarding the purpose and benefits of using visual supports in music therapy. Any additional relevant comments from other areas of the survey were also included. The ‘individual needs of the client’ was a prominent overarching response given across all relevant survey questions, with many RMTs noting specific instances where the use of visual supports enhanced the music-making experiences for the client. It was found that RMTs are using visual supports within music therapy practice for structuring sessions, activities or interactions in order to support their clients in engaging, communicating, learning & developing and exercising agency. RMTs also use visual supports in providing consistency for their clients across environments (as depicted in Figure 5). Additionally, Table 1 provides example responses from participants supporting these emergent themes and sub-themes.

Table 1.

Why Do RMTs Use Visual Supports Within Their Music Therapy Practice? (Themes, Sub-themes and Examples)

RMTs are using visual supports for…
RMTs are using visual supports to…
Comments from respondents
Structuring sessions
(80 comments)
indicate the session structure in order to assist the client to participate
decrease feelings of stress or anxiety for the client
prompt self in facilitation of sessions
“providing clear visual structure to the session” [R-11]
“to lessen the overwhelm of the unknown” [R-36]
“provide a routine for flowing from one activity to next” [R-08]
“reduces stress and anxiety by providing a clear outline of the process” [R-67]
“helps the MT know and remember session content” [R-51]
 
Supporting clients with engaging
(25 comments)
enhance client engagement and increase participation
further develop attention and focus within the session
“orients clients to the session activities resulting in increased engagement and focus” [R-65]
“to enable engagement and participation” [R-20]
“clients can be more actively involved and engaged” [R-35]
 
Supporting clients in communicating
(116 comments)
support general and overall communication goals
further develop receptive communication/ understanding
further develop expressive communication
enhance client-therapist communication in the session
 
“to offer a non-verbal method of communication for those for whom verbal communication is difficult” [R-17]
“to further assist with language development and alternative ways of intentional/functional communication” [R-28]
“helpful in receptive & expressive language for individuals with communication difficulties” [R-25]
“enable me to communicate with client[s] in their preferred form” [R-14]
 
Supporting clients in learning & developing
(52 comments)
assist with social & emotional skill development 
further support cognitive skills 
support memory recall skills
“to coach in cognitive and social skills” [R-18]
“helping children to cope with separation” [R-34]
“increase communication and social skills (waiting, turn taking)” [R-10]
“promote cognition, maintain/prolong attention span, connect musicking with reading skills” [R-12]
“to help prompt memory” [R-27]
 
Supporting clients in exercising agency
(45 comments)
support the client to have a voice/ autonomy within the session
provide clients with alternative ways of making choices as to what takes place in the session
“to support independence and self-efficacy” [R-50]
“extends client self-determination” [R-53]
“aid choice making and autonomy” [R-05]
“to provide choice and control for clients” [R-51]
“make choices/communicate their preference, allow for initiation” [R-10]
“it really encourage[s] my clients to make choices and express their choices confidently” [R-25]
 
Providing consistency and generalisation opportunities for clients
(40 comments)
use communication systems
within sessions that the client is using across environments
work within a team environment in order to be a part of a consistent approach to communication for the client
assist with generalising and transferring skills to other environments
“to support and enhance a program that has already been put in place by a speech therapist” [R-68]
“to support generalisation across school (consistent practice/security and consistency)” [R-13]
“consistency for communication across settings and help the client become proficient at using it” [R-51]
“provides them with learning environment/team around the learner immersed in consistent use” [R-53]
“to support generalisation of skills from the classroom to MT” [R-69]
“psycho-education for parent on how to assist child with transition at home” [R-34]
 

     Structuring. The theme of structuring captured respondents’ perceived value of using visual supports, such as a visual schedule, to provide a clear structure of the session, thereby reducing stress and anxiety for the client. This theme can be explained as visual supports being used by the music therapist to provide a clearly communicated set of methods/experiences that enable the client to understand the routine: including a start, middle and end to sessions, with transitions between each activity or section. Engaging. Comments under this theme included key words such as ‘participation’, ‘attention’ and ‘focus’. A link between the structuring and engaging themes was noted, as evidenced by several comments indicating that structure within sessions improves client engagement. Engaging can be described as clients being in the moment during the music-making as evidenced by exhibiting a response such as facial expression, body movement, physical or verbal response. From some comments it is noted that visual supports may assist with engagement.

     Communicating. Responses encom-passing the domain of communicating were coded across the sub-themes of general/overall communication-focused comments, responses more specifically about receptive communication, replies focused towards expressive communication, and comments regarding communication between the client and the RMT. Communicating encapsulates the nature of interactions within music therapy sessions as being between two or more people (e.g. music therapist and client, or client to client) utilising a range of mediums, including visual supports.

     Learning and Developing. Learning and developing as a theme within this study can be described as the systematic, step-wise progression for individual clients where change occurs across one or more developmental domains. Within these codes, responses referring to music therapy as a multi-sensory medium that engages auditory, visual, and tactile systems were also evident.

     Exercising Agency. Statements regarding client agency were coded under the sub-themes of supporting the client to have a voice/autonomy within the session, and to provide clients with alternative ways of making choices regarding opportunities. It was found that visual supports are being used by RMTs to assist clients’ agency in voicing their preferences (e.g. what is going to take place within the session, what role they will play, and what instruments/materials will be used). For the purpose of this study exercising agency can be described as music therapy participants influencing the course of their sessions and goals through the use of visual supports.

     Providing Consistency. Comments indicate that RMTs see benefits for their clients when they use communication systems within sessions that the client is using across environments. Providing consistency can be defined as the RMT actively seeking out communication and other program/goal information about their clients so as to utilise the same materials, devices and strategies within sessions as used by other team members working with this client, to provide opportunities for increased positive therapeutic outcomes.

Question 2: Who Are RMTs Using Visual Supports With?

     Respondents indicated that they use visual supports across a range of children and adult population groups including ASD, intellectual disability and acquired brain injury (see Figure 6). Of the 70 respondents who completed this question, the mode for ‘population groups’ was children with ASD (80%), with the next most represented category being children with a disability (65.7%). In addition, 41.4% respondents indicated that they also use visual supports in ‘other’ population areas including within parent-infant group work, with typically developing children, and within the areas of hearing loss, trauma, mental health and aged care.

Figure 6. Who Are RMTs Using Visual Supports With? (Population Groups)

     Throughout the various sections of the survey, respondents took the opportunity within the open-ended spaces to write about specific populations or clients where they had used visual supports. One respondent explained: “For mental health on a large shared screen, digital for active group participation. For children - at the beginning to set up structure and move throughout the program and choices” [R-04], while another wrote: “With adolescent/adult clients, can involve them in hand-drawing or digitally creating images of own” [R-18]. Another respondent explained the use of a visual schedule within their aged care work by writing: “Visual schedules are written out and each item is crossed out as we complete it” [R-47].

Question 3: What Types of Visual Supports Do RMTs Use Within Their Music Therapy Practice?

     The format or types of visual supports that RMTs are using within their music therapy practice range from simple hand-made flash cards to more complicated self-published storybooks and PECS (Picture Exchange Communication System) purchased resources as detailed at Figure 7. The mode for ‘type of visual supports’ is printed song lyrics (84.3%), followed by visual schedules (61.4%).

     For the purpose of this article, the two most utilised visual supports as indicated by RMTs are the primary focus, with additional formats to be addressed beyond this paper.

     Printed Song Lyrics. Of the respondents who ticked the box for ‘printed song lyrics’, 96.6% also chose one or more additional types of visual supports used within their practice. The respondents who ticked this option as their only use of visual supports within their music therapy practice (3.4%) also indicated that they work within the adult and aged care sectors.

     Visual Schedules. Respondents who ticked the box for ‘visual schedules’ (62%), also indicated that they use one or more additional types of visual supports within their practice. Additionally, these respondents practice music therapy with children or adults with ASD as one of their client population groups. Within the survey, RMTs were asked to tick as many boxes as apply to their experience of using visual schedules specifically within their music therapy practice. As indicated in Figure 8, the noted mode for visual schedule format was ‘top to bottom schedules’ (48.4%) followed by ‘left to right schedules’ (45.2%), and ‘flip-book schedules’ (41.9%), all using photos. Within this section of the survey, respondents (64.3%) also indicated their use of digital forms of visual supports within their practice, with utilised platforms including Proloquo2go, Visuals2Go, Core Chat, and Microsoft PowerPoint. With regards to digital forms of visual schedules specifically, 46.5% of RMTs responded that they have used a tablet, computer, or smartphone within sessions.

Figure 7. What Types of Visual Supports Do RMTs Use Within their Music Therapy Practice?

Figure 8. What Types of Visual Schedules Do RMTs Use Within Their Music Therapy Practice?

Question 4: What Do the Visual Supports that RMTs Are Using Within Their Sessions Look Like?

     In selecting, developing and creating visual supports to use within music therapy practice, the survey responses indicated that RMTs reflect on the needs of their clients first in designing or choosing how the visual supports will look. They are thinking about the visual supports being clear, simple, durable and of high quality, and they consider the text, images and colours used. Consistency of appearance within music therapy and across environments is seen as important. Additionally, 51.5% of the 64 respondents wrote about their individualised approach and the importance of factors including age-appropriateness, age-relevance, understand-ability and recognisability for their clients.

     Focusing on the physical product, comments made indicate visual supports used within music therapy should be simple, clearly set out and uncluttered with an emphasis on high quality and durability. Laminating visuals for longevity and ease cleaning for infection control was a noted comment, along with remarks on the value of using hook-and-loop fixtures (e.g. Velcro) for flexibility of delivery and display. One respondent noted that they do not laminate the song lyric sheets they use with their clients within an aged care setting due to the ‘glare’ that can be experienced, while another wrote about their use of ‘matt’ rather than ‘glossy’ laminate pouches/film when producing visual supports to alleviate this issue.

     Comments on the text that appears on visual supports focused on font size, font type, the amount of text used and other formatting choices. Respondents indicated that RMTs need to think about the needs of the client (e.g. development, age, visual skills) and if they are participating within individual or group music therapy sessions when deciding on an appropriate font size. It was indicated that the best fonts to use are simple, for example, “print is in large sans serif… or serif fonts” [R-47] and “nothing too fancy or curly” [R-63], with one respondent noting a font change to Comic Sans [MS] primarily for the letter ‘a’ to appear as ‘a’ for consistency was of benefit to their clients. Several respondents indicated that it is important for RMTs to consider limiting the number of words they use, suggesting that “limited or no written words” [R-39] or a “one/two-word text limit” [R-42] be applied.

     Responses on the image that appears on visual supports focused around the type (e.g. photos, illustrations or line drawings), size, colour and the overall aesthetic value. Again, the needs of the client were prioritised by the respondents with emphasis towards simple images being beneficial. One RMT indicated that they tend to use line drawings for their clients as they are “less specific and more generalisable” [R-13] while another RMT stated “photos are important to show ‘real’ images” [R-51]. Colour choice was another theme to emerge from the analysis with 13 comments relating to making images colourful, and the use of background colour for categorising and assisting client’s understanding. Words such as “attractive” [R-71], “engaging” [R-61], “cute” [R-32], and “interesting” [R-27], were used in describing how the images should look in order to benefit clients within music therapy sessions.

     Additional comments indicated that RMTs believe it is important that visual supports for clients be “easy to hold/carry” [R-55] and that the format chosen can “be re-ordered easily” [R-58]. Consideration towards using borders on images and having rounded corners was also noted. When RMTs were asked about how they source their visual supports, the mode was “I make them myself” [R-03] (92.9%), with the next most represented category being ‘My workplace provides them’ (68.6%). For example, “At my workplace, we have a therapy assistant who handles visual supports - we explain what visuals we want to use and she prepares them”[R-59] and also, “I work closely with the speech therapy department at my school to create visual supports”[R-49].

Question 5: How Are RMTs Using Visual Supports Within Their Music Therapy Sessions?

     Throughout the survey responses, RMTs took the opportunity to share their practice-knowledge with regards to the application of visual supports within music therapy sessions. It was found that RMTs reflect on the individual client needs first when considering visual support delivery in music therapy sessions and the importance of communication within sessions, believing a consistent approach will benefit clients.

     When commenting on communication within sessions, respondents highlighted the importance of RMTs using verbal cues to accompany the use of visual supports. Comments included the use of “simple clear language with use of visuals” [R-08] and “visuals are often accompanied by saying the word written on the visual” [R-68]. Comments on the nonverbal language from the music therapist included “animation, energy/affect” [R-08] and “usually the aids are supported with gestures” [R-44].

     Under the sub-theme of planning and facilitating sessions, RMTs indicated that it is advisable to be well organised before sessions if using visual supports and that the practical day-to-day usability of visual supports is important. Comments on the value of using visual supports to structure sessions included: “[Visual supports] provide a point of reference for sessions and clients” [R-51] and “visual supports [are] referred to at beginning of the session, thereafter as required”. The location and positioning of the visual supports were noted in the comment: “I put them in the same space in a similar pattern to achieve familiarity and sense of predictability so that clients feel safe” [R-70]. With regards to transitions between activities, RMTs shared practical strategies. Comments included “[Visual supports] build anticipation in turning the page of flip-book to enhance attention within activities” [R-90]. The importance of the visual supports being utilised in a way that assists clients to be able to confidently make choices was highlighted as “not too many options to overwhelm” [R-23].

Question 6: Have RMTs Received Training in Using Visual Supports Within Their Sessions?

     All respondents completed the visual supports training question on the survey with only 56.3% indicating that they had been provided with visual supports training. Of these affirmative responses, several RMTs indicated that they had participated in training in more than one situation with training provided by their music therapy employment facility/program (70%), at a conference workshop (25%), within their music therapy course work at University (17.5%), or through ‘other’ means (25%) indicated as University training placements, from families of clients, and through observing other RMTs. Seventy-six percent of RMTs indicated they would benefit from visual supports training and suggested various learning formats, including hands-on workshops, webinars or online modules with an emphasis on the value of peer-learning. In practical terms, they would like further information on current communication systems in use, and how to make population specific materials using current technology software and applications.

Additional RMT Attitudes and Beliefs

     Within the final section of the survey, challenges and concerns were noted, and included: “I have found this very difficult and haven't got a system I am happy with yet to deliver visual supports” [R-69], “A lot of them take time to make and as I'm not a speech expert it also take time for me to learn using them [sic]. Then in private practices it's the cost of buying some of them (e.g. PODD electronic version is very expensive)” [R-25] and “keeping them organised can be challenging” [R-59]. Some respondents commented on the difficulties in finding a balance between the utilisation of visual supports within sessions and the actual music-making, expressing concern that the visual supports may in fact distract from the music. Other respondents noted visual schedules may restrict their flexibility, making it difficult to change the session plan or next activity/experience in the moment, as and if needed (see Table 2).

     Other comments, not within the stated themes, linked to career-related changes in views to using visual supports and attitudes to how much they should be used. For example, respondent 61 wrote “I didn't use them early on in my career as an RMT. Now I use them in most of my work.” While for this same question, respondent 62 wrote “Sometimes the visual supports can be overused. I personally don't use them a lot.” This gives further insight and guidance towards the development of applications of visual supports within music therapy practice.

Table 2

Concerns Expressed by RMTs in Using Visual Supports Within Their Music Therapy Practice

Comments from respondents
“don't want them to divert attention from music” [R-09]
“I find it can inhibit me form being responsive when the structure is predetermined on a board” [R-15]
“I sometimes find it a bit disruptive to the flow of the session…” [R-24]
“I use it when necessary, but not as a "must" because "real life" is not always with Aided Visual Supports and MT is an environment where there can be enough "support" without it” [R-31]
“but also to not be limited or restrained by it” [R-51]
“knowing when to not use them! (i.e. when they interfere with the flow of therapy)” [R-58]
“we need to keep a focus on the primacy of the musical interactions and musical engagement in our practice as MT” [R-58]
“presenting the visuals in a way that assists, rather than detracts from, the musical experience” [R-59]
“finding balance between structure using schedule and also flexibility” [R-59]
“sometimes the visual supports can be overused. I personally don't use them a lot as I aim to help the clients deal with flexibility - coping when things aren't "planned" [R-62]
“used to enhance the session but not control the session” [R-65]

Discussion

     This research project reports on the findings from a survey of RMTs in their utilisation of visual supports within their music therapy practice. In seeking to discuss the results of this project, it is noted that the existing music therapy literature addresses AAC broadly within practice, while this project focuses on one specific AAC strategy, visual supports. Therefore, this causes challenges for comparison and discussion. Within the results reported by Gadberry & Sweeney (2017) it was found that 55.1% of surveyed practicing music therapists (mostly from the United States of America) indicated that they provide services to clients who use AAC. Additionally, 61.6% of surveyed music therapists reported using various forms of AAC, including visual supports, with their clients during music therapy sessions. The figure of 98.6% surveyed RMTs in our current study who have used visual supports within their music therapy practice in Australia is of interest when regarding the previous literature. While it is not possible to undertake a direct comparison of these figures due to the number of variables and differences in surveys and focus countries, it does raise the consideration that perhaps there has been an increase in use of AAC by music therapists in more recent years, or that Australian music therapists are utilising AAC, specifically visual supports, more widely with the population groups they serve.

     According to the survey by Hahna et al. (2012), Australian music therapists are amongst those most open to including the use of technology within their practice. This supports the findings of this current survey where it was found that 64.3% of respondents included digital forms of visual supports within their practice, with 46.5% of the RMTs who use visual schedules within their sessions stating they have used digital versions of this type of visual support.

     Based on the survey responses and supported by the literature, it appears that RMTs are primarily using visual supports with people with ASD. However, respondents indicated there are also several other population groups who appear to benefit from visual supports within music therapy, including families with complex needs (parent-child dyads), elderly clients, and adults with mental health issues. It was positive to note that a person-centred communication approach (McNaughton et al., 2019) was widely evident within the open-ended responses provided on this survey in the current project.

     Our survey results show that RMTs understand: a) the importance of supporting clients who have additional communication needs by using visual supports; and b) that it is important for RMTs to make decisions about therapeutic approaches and strategies with the needs of the client being prioritised over their own preferences or current skill set with regards to visual supports. These findings are encouraging to note, given that Australian disability legislation and the National Disability Insurance Scheme requires that service providers ensure that appropriate and reasonable adjustments are made for people with disabilities (Australian Government, 1992; Australian Government Department of Education, 2005; Cameron, 2017). However, without adequate understanding of this legislation and adequate training, RMTs may be at risk of non-compliance with Australian law with regards to the use of AAC, specifically visual supports, within music therapy practice. Regardless of this finding, RMT respondents still indicated that there is a need for further evidence-based training at both university level and for professional development of experienced practitioners.

     To understand why and how RMTs are using visual supports within their music therapy sessions it is important to consider that Australian music therapists tend to work at more than one facility and across several population groups within their working week (Jack et al., 2016). With this in mind, it was shown that RMTs are primarily using visual supports in order to assist their clients with communication and to structure music therapy sessions in order to reduce stress or anxiety for their clients. Within my work and observations of RMTs facilitating sessions I have at times noted challenges with the delivery of visual supports and have realised that skills and techniques are required in order to calmly and systematically use visual supports within sessions for the benefit of the clients. Like other music therapy skills, it takes practice, knowledge and time in order to become competent at using visual supports.

     In addition to these observations, I have also experienced situations where the actual physical visual support product being used could be designed in a way that would further benefit the clients. It may be that the font is too small, not clear, the resource is crumpled and therefore not functional, or the format chosen is not suitable for the client. Comments from RMTs support my observations through the sharing of their own ‘what works’ approach as in the RMT’s use of a Comic Sans [MS] font for the benefit of the client, potentially to ensure consistency in visual appearance of the letter ‘a’ when learning to hand-write or read. The use of laminating and hook-and-loop products also featured in the comments with regards to producing visual supports that are durable, functional and reusable. Based on responses regarding the physical products used within practice, it can be said that the aesthetic values are also an important consideration when choosing to use a visual support.

     With regards to training for RMTs in visual supports, there appears to be a need to increase training at university level teaching with only 9.5% of respondents indicating that they received instruction during their music therapy coursework. Furthermore, there seems to be a need to provide professional development opportunities to current RMTs as evidenced in the responses with 43.6% saying that have not received any training in visual supports, and 71.8% indicating that they would like training. There were also several comments about the importance of RMTs learning from each other with regards to visual supports within practice, therefore indicating the need for networking opportunities through workshops or online forums where this practice-knowledge can be shared amongst professionals. Indications are that RMTs value learning from colleagues who are also practicing RMTs, and experiencing similar situations and challenges in real-world application of visual supports in music therapy practice.

     Concerns voiced by some RMTs (13% of respondents) as indicated in Table 2 included getting the balance right during music therapy sessions, and not allowing visual supports to dominate or get in the way of the music-making. Contrasting viewpoints were expressed by respondents in the open-ended ‘further information’ section on the survey whereby one respondent explained that they did not use visual supports early in their career, but now use them often [R-61]. For this same question, another experienced respondent indicated that they don’t use visual supports very often [R-62]. Potentially, different perspectives may be indicative of the broader opinions and experiences of RMTs and may assist those endeavouring to provide tailored training or support to RMTs on this topic. These beliefs affect the way a best-practice framework should be developed, whereby these concerns are addressed so as to increase the potential uptake of this approach.

     Limitations of this study include the finite opportunity provided for RMTs to participate, with no follow-up interviews of survey respondents. As noted in the results, 98.6% of respondents indicated that they have used visual supports within their music therapy practice. Potentially respondents may have only been those who were interested in the topic, raising a non-response bias; a limitation supported in the music therapy literature exploring online or in-person voluntary surveys (Hahna et al., 2012; McCarthy et al., 2008). As this is the first known study within Australia on the utilisation of visual supports in music therapy practice, it is viewed as a starting point for future research that can aim to extend these results by including a larger sample size. Further practitioner research is also needed within this field, particularly focused towards the application and effectiveness of visual supports within music therapy practice, along with the development of training manuals or programs in order to provide postgraduate music therapy students with practical training and to upskill current practicing music therapists. Collaboration and development of further appropriate research methodologies, in consultation with others working in this field, will strengthen this important area of research.

Conclusion

     This project has investigated why music therapists use visual supports, who they use them with, what format these tools take, and how they are delivered. In addition, the area of training in the use of visual supports for music therapists was addressed. Through surveying Australian RMTs at the AMTA National Conference 2018 it was found that most (98.6%, n=70) respondents have used visual supports within their music therapy practice, and the results suggest that these tools benefit clients with additional communication support needs as applied across different population groups. The findings of this study may be of use to RMTs in validating and fine-tuning their current practice experience, while also expanding their knowledge of the range of visual support formats and delivery applications within practice. In turn, participants attending music therapy services will reap the benefits of a more highly skilled workforce. Furthermore, these findings may be of use to researchers in the field as a foundation for addressing the development of best-practice, evidence-based guidelines for utilising visual supports within music therapy practice. Additionally, in the context of interprofessional practices, the findings of this study may be useful to other allied health and educational disciplines. This project has prompted new evidence-based thinking about the use of visual supports by music therapists for the benefit of individual and group music therapy clients.

Acknowledgements

     We would like to thank the Australian Music Therapy Association for agreeing to this survey being conducted at the National Conference, with particular thanks to the 2018 New South Wales Conference Committee. Appreciation is also expressed to the RMT respondents who made this article possible, and to Kate Penson for her assistance and support. Thank you to Dr Jennifer MacRitche for guidance during the analysis phase, and to Dr Anne Hogden and Dr Catherine Kaplun for assistance with the final review. Thank you to all of the clients I have worked with over the years who have taught me so very much about the utilisation of visual supports within music therapy practice. I am grateful and appreciative of our time music-making together. Finally, I would like to express appreciation to my co-author and primary doctoral supervisor, Dr Alison Short, for her ongoing support and mentorship.

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Appendix A

Visual Supports in Music Therapy Practice Examples

Example 1
Flip-book Schedule Utilising Illustrations & Photos
A close up of a piece of paper

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A close up of a box

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A close up of a box

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Example 2
Left-to-Right Schedule Utilising Illustrations & Photos
A picture containing refrigerator, photo, kitchen, hanging

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Example 3
Song-board “Three Jellyfish"
Example 4
Instrument Choice Board Utilising Photos